Please remit your insurance premium to :-

Bank : CIMB Islamic Berhad
Account Name : NZ Network Management Services Sdn Bhd (Etiqa Takaful Corporate Agency)
Account No : 8602 323 535


* Your Choice
* Name
* Matric No.
  Gender Male  Female
* Date of Birth / /
* Age
* Passport No.
* Visa Details
  Applicant's mailing address (in Malaysia)
* Number & street
* Suburb/Town
* Post/zip code
* State
* Country MALAYSIA
  Applicant's Contact Details
* Email (Login ID)
* Password
* Confirm Password
  Married Status Single   Married   Divorce  
  Proof Of Payment
  Upload Proof Of Payment
File allowed: .pdf, .jpg, .png, .gif only
Size: Max 900kb
  Captcha Code CAPTCHA code

I/We hereby declare that the information given in this application form are true and that I/the life insured did not suffer from any of the pre-existing conditions at the time of this policy was taken up. I agree that in the event that I make, or have in the past made, any false or untrue statement and/or suppressed and/or concealed any materials facts in respect of my/the life insured's health and condition, the company shall absolutely forfeit my/the life insured's right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof.

I accept the above declaration.