MAX-KERP
Name of Insured : ____________________ (M / F) D.O.B.: ________________ Age :
_________
Name of Payor : ____________________
Premium : ________ Fund : _______ Payment mode :
_________ Years : _________
No Description Protection Benefits Details
1Life
a) Death
b) Commit Suicide
c) TPD
d) Presumptive TPD
RM __________
Policy issue after 13 months RM
__________
F 0 E 8 Sickness RM
__________
F 0 E 8 Accident RM
__________
Loss 2 limbs or loss all sight of both eyes;
or loss 1 limb and all sight of 1 eye
RM __________
238 Critical Illness
(60 days waiting
period)
RM __________
RM __________
a) 1/35 Diagnosis of the specified
diseases at 100%
RM __________
b) F 0 E 8 Baloon Angioplasty RM
__________
F 0 E 8 Coronary Laser RM
__________
F 0 E 8 Coronary Artherectomy RM
__________
3Saving
Contribution
Co
Emp
%
%
Year
Company
Employee
1
2
Total Saving
RM _____________
