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Covers up to RM80,000
3-minute sign-up,
cancel anytime!
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I hereby consent to opt-in for the free coverage and agree
to be contacted if necessary for verification or servicing
purposes.
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By clicking the “Activate” button below, you
hereby express your consent to share your Personal Data,
agree to receive marketing, promotional and cross sell
offers, accept the Privacy Policy and read the Product
Disclosure Sheet (PDS).
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FATCA (US Foreign Account Tax Compliance Act) Declaration
Click
here
to read more about FATCA Declaration.
Are you a US Tax obligated person?
Common Reporting Standard (CRS) Declaration
Click
here
to read more about Common Reporting Standard Declaration.
(Note: Only applicable to a policy which is subject to the
OECD Common Reporting Standard)*
Are you currently a Tax resident outside Malaysia?
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No, I am currently solely a Tax Resident in Malaysia
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Yes, I am currently a Tax Resident of the following
countries: (Please fill the Foreign Tax Residency
Self-certification Form)
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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.
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I/We have read and agree to the Beneficial Owner, FACTA,
and CRS Declaration for Member and Life(s) to be Assured
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I/We have read and fully understand the terms, product
benefits, exclusions, premiums, fees and charges as set
out in the Product Brochure, Product Disclosure Sheet,
Terms and Conditions, and Important Notice.
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I/We understand that this information will be used as the
basis and an integral part of the policy to be issued, and
any false information may result in the nullification of
coverage and rejection of any claims by the Insurer.
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I/We would like to receive updates and information about
the Company, products, services, promotions, charitable
causes or other marketing information from relevant third
parties of the Company.
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I/We understand and agree that the Company may ask for
supporting documents for the purposes of identification
and to verify my relationship with the Life(s) Assured. I
understand and agree that the Company may not process my
application if I fail to provide the requested supporting
documents within the time specified by the Company.
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I acknowledge and agree that my application may be subject
to further underwriting review. The insurer reserves the
right to defer, postpone or decline my application based
on the information provided, and I will be notified
accordingly if further action or documentation is
required.*
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By clicking the "Next" button below, you hereby
express your consent to share your Personal Data, agree to
receive marketing, promotional and cross sell offers,
accept the
Privacy Policy
and read the Product Disclosure Sheet (PDS) by the
Business Partner.*
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I/We hereby declare and confirm that the specimen
signature and image of NRIC provided with this application
is my/our signature and NRIC. I/We understand and agree
that the specimen signature and NRIC provided with this
application shall be used by the Company as basis for the
approval of all transactions requiring my/our assent
and/or signature, and for any other servicing or identity
verification purposes.
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I/We hereby confirm that the information, statements and
answers in this application form together with any other
documents submitted in connection with this application
form and all statements made and answers given to the
Company are complete and accurate (“the
Information”). I/We understand that the Information
given by me/us is relevant to the Company in deciding
whether to accept my/our application or not, and the rates
and terms to be applied. The Company may terminate or void
the application (if issued), deny or reduce my/our claim,
or change or vary the terms of coverage, if there is any
non-disclosure, misrepresentation, misstatement,
inaccuracy or omission.
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Beneficial Owner Declaration
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.
Are you the beneficial owner who ultimately owns and/or has
effective control over this proposed insurance?
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Please proceed to activate and confirm the declaration.
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