Proposal Form


Travel PA Takaful

Trip Type : Destination Area :
select
Start Date :
RadDatePicker
Open the calendar popup.
Type of Plan :
select
End Date :
RadDatePicker
Open the calendar popup.
Coverage Type :
select
Trip Length :


Correspondence Address (Note : Please enter the correspondence address if it's not the same as the registration address)

Address 1 : PostCode :
Address 2 : City :
Address 3 : State :
select
Email :


Proposer Details

Relationship :
select
 
Name (as per IC/Other ID/ Passport) :
select
 
ID Type :
select
IC/Other ID/ Passport :  
Gender Marital Status
select
Nationality
select
Date of Birth :

e.g (dd/mm/yyyy)  
Occupation :
select
 
Mobile Number :  
Home Phone No. : Office Phone No. :
Fax Number :
  |        Click 'Add' to add one or multiple proposers.


Nominee Details

Beneficiary Name :   Beneficiary Address :  
Beneficiary Passport/IC :   Beneficiary Relationship :
select
 
Beneficiary Birthday :

e.g (dd/mm/yyyy)  
Beneficiary Share :  
Total shares for all nominee must be 100%
  |        Click 'Add' to add one or multiple nominees.