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CHOOSE A SUITABLE PLAN FOR YOU

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PLAN SUMMARY
RM80,000 + TIV
45 Critical illnesses
RM80,000 + TIV
Death due to illness or natural cause
RM80,000 + TIV
Total and Permanent Disability
(Due to illness)
RM2,400
Medical Expenses Allowance
(Private Hospital Only)
RM160,000 + TIV
Accidental Death
RM160,000 + TIV
Total and Permanent Disability
(Due to accident)
RM240/day
Hospitalisation Benefits
(Government Hospital)
RM160/day
Hospitalisation Benefits
(Private Hospital)
RM2,000
Funeral Expenses
(Based on the Net Asset Value (NAV))
Total Investment Value (TIV)
PLAN SUMMARY
RM120,000 + TIV
45 Critical illnesses
RM120,000 + TIV
Death due to illness or natural cause
RM120,000 + TIV
Total and Permanent Disability
(Due to illness)
RM3,600
Medical Expenses Allowance
(Private Hospital Only)
RM240,000 + TIV
Accidental Death
RM240,000 + TIV
Total and Permanent Disability
(Due to accident)
RM300/day
Hospitalisation Benefits
(Government Hospital)
RM240/day
Hospitalisation Benefits
(Private Hospital)
RM2,000
Funeral Expenses
(Based on the Net Asset Value (NAV))
Total Investment Value (TIV)
PLAN SUMMARY
RM250,000 + TIV
45 Critical illnesses
RM250,000 + TIV
Death due to illness or natural cause
RM250,000 + TIV
Total and Permanent Disability
(Due to illness)
RM3,600
Medical Expenses Allowance
(Private Hospital Only)
RM500,000 + TIV
Accidental Death
RM500,000 + TIV
Total and Permanent Disability
(Due to accident)
RM300/day
Hospitalisation Benefits
(Government Hospital)
RM240/day
Hospitalisation Benefits
(Private Hospital)
RM2,000
Funeral Expenses
(Based on the Net Asset Value (NAV))
Total Investment Value (TIV)

PAYMENT METHOD


BENEFICIAL OWNER DECLARATION (TO BE COMPLETED BY MEMBER)

If the answer is "NO", please complete the Questionnaire On Beneficial Owner and submit it along with a Statutory Declaration signed by the beneficial owner. Please contact the Authorised Representative for a copy each of the Questionnaire On Beneficial Owner and the Statutory Declaration.

FATCA (US FOREIGN ACCOUNT TAX COMPLIANCE ACT) DECLARATION (MEMBER AND LIFE(S) TO BE ASSURED)

FATCA (US Foreign Account Tax Compliance Act) FATCA

Foreign Account Tax Compliance Act (FATCA) is a United States of America (US) law, which affects Financial Institutions worldwide, aims at reducing tax evasion by US persons. FATCA requires Financial Institutions outside the US to provide information regarding their customers who are US persons to the US Inland Revenue Service (US IRS).

In compliance with the above, Great Eastern Life Assurance (Malaysia) Berhad (the "Company") is required to obtain information pertaining to the tax residency of each account holder pursuant to FATCA.

FATCA (US Foreign Account Tax Compliance Act) Declaration

I/We agree that I/we will update the Company promptly of any change or addition to the information provided herein about me/us, the life assured, the beneficiary named in this proposal or of the policy and any other relevant persons (if any, and collectively with the life assured and the beneficiary the "Relevant Persons") as the Company may reasonably require. I/We further agree, and represent to the Company that each Relevant Person has agreed when information about him is provided to the Company, that the Company may disclose such information for the purpose of its compliance with any applicable rules, laws and regulations, codes of practice or guidelines or to assist in law enforcement and investigations by relevant authorities.

I/We understand that the Company will not be liable for any costs or losses that may be incurred to me/us or any of the Relevant Persons due to actions of the Company permitted herein. In this connection, I/we agree to indemnify the Company against all claims of the Relevant Persons for the aforesaid costs or losses. I/We further understand that my/our failure to fulfill any of the obligations herein, or any of untrue or inaccurate representations given herein, will entitle the Company to deduct or withhold such amount from any payment payable under the relevant policy, and/or to terminate the policy without being held liable, to the extent permitted by law, and I/we will indemnify the Company against all costs and losses that may be incurred to it therefrom.

I/We agree to complete and sign such documents and do such things for purposes reasonably required by the Company to evaluate my/our proposal and to provide the products or services which I am/we are applying for.

COMMON REPORTING STANDARD (CRS) DECLARATION (MEMBER AND LIFE(S) TO BE ASSURED)

Common Reporting Standard (CRS)

The Company is required to collect information regarding the tax residency status of each Account Holder in order to comply with the Income Tax Act 1967 and the Income Tax (Automatic Exchange of Financial Account Information) Rules 2016 ("collectively referred to as Malaysian Laws on International Tax Compliance"). The Malaysian Laws on International Tax Compliance implement the standard for automatic exchange of financial account information in tax matters, commonly known as Common Reporting Standard ("CRS"), developed by the Organisation for Economic Co-operation and Development ("OECD").

Pursuant to the Malaysian Laws on International Tax Compliance, the Company may be legally obliged to share the information provided by an Account Holder and other financial information with respect to the financial accounts of an Account Holder with the Inland Revenue Board of Malaysia ("IRBM"). IRBM may exchange such information with the tax authorities of another jurisdiction or jurisdictions in which the Account Holder may be tax resident pursuant to an intergovernmental agreement to exchange financial account information.

Each jurisdiction has its own rules for defining tax residence. If you have any questions on how to determine your tax residency status, you should consult your tax adviser or the information could be obtained at the OECD automatic exchange of information portal [http://www.oecd.org/tax/transparency/automaticexchangeof information.htm]. The Company will not be in a position to provide assistance beyond the information set out herein.

Note: In the case of a Cash Value Insurance Contract or an Annuity Contract, the Account Holder is any person entitled to access the Cash Value or change the benficiary of the contract. If no person can access the Cash Value or change the beneficiary, the Account Holder is any person named as the owner in the contract and any person with a vested entitlement to payment under the terms of the contract. Upon the maturity of a Cash Value Insurance Contract or an Annuity Contract, each person entitled to receive a payment under the contract is treated as an Account Holder.

Common Reporting Standard (CRS) Declaration

I certify that I am the account holder (or I am authorised to sign for the account holder) in respect of this policy.

I acknowledge that the information contained in this form, including information regarding the Account Holder and any reportable account(s) may be reported to IRBM and exchanged with the tax authorities of another country or countries in which the Account Holder may be tax resident, pursuant to intergovernmental agreements to exchange financial account information.

I declare that all statements made in this form are, to the best of my knowledge and belief, correct and complete. I undertake to inform the company within 30 days if there is a change in circumstances that affects the tax residency status of the Account Holder or causes the information in this form to be incorrect or incomplete. I shall provide the Company with an updated self-certification form within 90 days of such change in circumstances.

I understand that any person who provided any incorrect information required to be provided under the Malaysian laws on International Tax Compliance shall (unless he can show that he provided such incorrect information in good faith) be guilty of an offence and is punishable in accordance with the prevailing Common Reporting Standard Rules and Regulations.

I agree to complete and sign such documents and do such things for purposes reasonably required by the Company to evaluate my proposal and to provide the products or services which I am applying for.



MEMBER AND/OR LIFE(S) TO BE ASSURED DECLARATION

The term "Company" shall refer to Great Eastern Life Assurance (Malaysia) Berhad.

The terms "we/us/our" shall refer to the Life(s) to be Assured, if any.