SULIT / CONFIDENTIAL

Kod Sumber/Source Code

BORANG PERMOHONAN PEMBIAYAAN / FINANCING APPLICATION FORM

(Sila gunakan huruf besar dan tandakan di mana perlu) / (Please write in full block letters and tick where applicable)

Cawangan / Branch : Tarikh / Date : Hari/ Bulan/ Tahun/

DD MM YYYY

BAHAGIAN A / PART A : JENIS PEMBIAYAAN / TYPE OF FINANCING

PERIBADI / PERSONAL PERIBADI / PERSONAL

Peribadi-i / Personal-i Pembiayaan ASB-i /ASB Financing-i Dengan Takaful / With Takaful
Pendidikan-i / Education-i Aliran Tunai-i / Cash Line-i Tanpa Takaful / Without Takaful
Lain-lain / Others :

HARTANAH / PROPERTY TAKAFUL / TAKAFUL

HomeFinancing-i
Pembiayaan Rumah-i /Home Financing-i Pelan Takaful Bertempoh Gadai Janji Berkurangan /
Mortgage Reducing Term Takaful
LandFinancing-i
Pembiayaan Tanah-i /Land Financing-i
Pelan Takaful Empunya Rumah & Isi Rumah /
Pembiayaan Semula Rumah-i / Home Refinancing-i
Houseowner / Householder Takaful Plan
Pembiayaan Premis Perniagaan-i / Business Premises Financing-i Pelan Takaful Bertempoh Gadai Janji Bertahap /
Lain-lain / Others : Mortgage Level Term Takaful

TUJUAN PEMBIAYAAN / PURPOSE OF FINANCING PEMBIAYAAN TAKAFUL OLEH / TAKAFUL FINANCING BY

Kediaman Sendiri / Owner Occupied Bank / Bank
Perniagaan / Business Pembiayaan Sendiri / Own Financing
Pelaburan / Investment
Sektor Keutamaan (Kediaman Sendiri) / Priority Sector (Owner Occupied)

AR-RAHNU DARI MANA ANDA TAHU TENTANG AR -RAHNU KAMI /

Ar-Rahnu Tawarruq HOW DO YOU KNOW ABOUT OUR AR- RAHNU
Lain-lain / Others : Akhbar Harian / Daily Newspaper Media Sosial / Social Media
Sistem khidmat pesanan ringkas Rakan / Friend
TUJUAN PEMBIAYAAN / PURPOSE OF FINANCING / SMS
Kegunaan sendiri / Personal use Lain-lain / Others :
Lain-lain / Others :

BAHAGIAN B / PART B MAKLUMAT PEMBIAYAAN / FINANCING DETAILS (Tidak terpakai untuk Ar-Rahnu / Not applicable for Ar-Rahnu)

Amaun Dipohon / Financing Amount Tempoh Pembiayaan / Tenure Program Pembiayaan / Financing Programme

RM tahun / year(s) Pakej / Package

, ,
Bukan Pakej / Non-Package
Jenis Permohonan / Application Type
Profesional / Professional
Individu / Individual
Lain-lain / Others :
Bersama / Joint :
Penjamin / Guarantor

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Bahagian C / Part C: Maklumat Pelanggan / Customer Details

(Ar-Rahnu: Terpakai untuk pelanggan baharu sahaja / Ar-Rahnu: Only applicable for new customer only)

CIF:
Status Pelanggan / Customer Status : Pemohon / Applicant Pemohon Bersama/ Joint Applicant Penjamin / Guarantor
Nombor CIF Pelanggan Utama (untuk permohonan bersama / penjamin) / Main CIF Number (for joint applicant / guarantor) :

Gelaran / Title Encik / Mr Puan / Mrs Cik / Miss Lain-lain / Others :

Nama Penuh / Full Name

No. KP Baharu / New NRIC No. No. KP Lama / Old NRIC No. Lain-lain / Others
- -
Tarikh Lahir / Date of Birth Tempat Lahir / Place of Birth Umur / Age Jantina / Gender
Hari/ Bulan/ Tahun/ Tahun/ Lelaki / Male Perempuan / Female
DD MM YYYY YYYY
Alamat Tetap / Permanent Address

Poskod / Postcode Bandar / City Negeri / State

Kewarganegaraan / Citizenship
Alamat Kediaman / Residential Address Sama seperti Alamat Tetap / Same as Permanent Address Penduduk Tetap /
Warganegara / Citizen
Permanent Resident
Warga Asing / Foreigner
Negara asal / Country of origin:
(Sila nyatakan no. diberikan BNM / Please specify
BNM assigned number):

Poskod / Postcode Bandar / City Negeri / State

Alamat Surat Menyurat / Correspondence Address

Alamat Tetap / Permanent Address Alamat Kediaman / Residential Address Alamat Pejabat / Office Address
No. Telefon Bimbit / Mobile Phone No. No. Telefon Rumah / Home Telephone No. Alamat Emel / Email Address

*Bangsa / Race Melayu / Malay Cina / Chinese India / Indian Lain-lain / Others :

Agama / Religion Bumiputera / Bumiputera Ya / Yes Tidak / No

Jenis Kediaman / Residence Type
Milik Sendiri / Own Premises Tinggal Bersama Keluarga / Living with Family Sewa / Rent Majikan Sediakan / Provided by Employer

Tahap Pendidikan / Education Level

Rendah / Primary Menengah / Secondary Sijil / Certification

Diploma / Diploma Ijazah Sarjana Muda / Degree Ijazah Sarjana / Masters

Kedoktoran / PhD Sijil Profesional / Professional Certification Lain-lain / Others :

Status Perkahwinan / Marital Status

Bujang / Single Berkahwin / Married Bercerai / Divorced Balu / Widow Duda / Widower

Bilangan tanggungan termasuk suami/isteri / No. of dependents including spouse

Nama Ibu / Mother’s Maiden Name

Saya mempunyai talian persaudaraan dengan kakitangan Bank Islam / I have family members working in Bank Islam . Ya / Yes Tidak / No

Nama Penuh Kakitangan / Staff's full name Hubungan / Relationship

*Data sensitif / Sensitive data 12/2022

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BAHAGIAN D / PART D : Maklumat Pekerjaan/Perniagaan / Employment / Business Details

Klasifikasi / Classification
Majikan / Employer Bekerja Sendiri / Self Employed / Own Account Worker
Kakitangan Kerajaan / Government Employee Pekerja Keluarga Tanpa Gaji / Unpaid Family Worker
Kakitangan Swasta / Private Employee Tidak Bekerja / Unemployed
Kakitangan Entiti Pelaporan / Reporting Entity (RE) Employee Bukan Tenaga Buruh / Outside Labour Force

Status Pekerjaan /
Employment Status
Tetap / Permanent Tempoh Percubaan / Probation Period
Sementara / Temporary Bekerja Bebas / Freelance
Separuh Masa / Part Time Kontrak / Contract
Lain-lain / Others : Tarikh tamat kontrak / End date of contract :

Nama Majikan/Perniagaan / Name of Employer/Business

Sektor Pekerjaan/Perniagaan* / Employment/Business Sector* Kod* / Code* Jawatan / Designation Kod Pekerjaan* /
Occupation Code*

*for Bank use only *for Bank use only *for Bank use only
Alamat Pejabat / Office Address

Poskod / Postcode Bandar / City Negeri / State

No. Telefon Pejabat / Office Phone No. Alamat Emel Pejabat / Office Email Address

Tarikh Mula Berkhidmat / Employment Start Date

Hari/ Bulan/ Tahun/
DD MM YYYY
Nama Majikan/Perniagaan Dahulu/ Name of Previous Employer/Business (jika berkenaan / if applicable)

Jawatan / Designation Pengalaman Bekerja / Working Experience

tahun / years bulan / months

BAHAGIAN E / PART E : Maklumat Pendapatan / Income Details

Pendapatan Bulanan / Monthly Income Pendapatan Lain (Bulanan) / Other Source of Income (Monthly)
RM , , RM , , Nyatakan / Please specify :

Pendapatan Tahunan / Yearly Income Sumber Pendapatan Lain / Other Source of Income
RM , , RM , , Nyatakan / Please specify :
Sila nyatakan sumber pendapatan, sekiranya tempoh pembiayaan melebihi umur persaraan / If financing tenure exceed retirement age, please state
source of income

KWSP / EPF Pendapatan Sewa / Rental Income

Simpanan/Simpanan Tetap/ASB / Lain-lain / Others :
Savings/Fixed Deposit/ASB

BAHAGIAN F / PART F : Maklumat Pembiayaan Dengan Institusi Bukan Kewangan / Financing With Non-Financial Institutions Details
(Tidak terpakai untuk Ar-Rahnu / Not applicable for Ar-Rahnu)

1. Nama Institusi / Name of Institution Jenis Pembiayaan / Financing type

Bayaran Bulanan / Monthly Instalment : RM , , Baki Tempoh Pembiayaan / tahun bulan

Remaining Financing Tenure : /years /months

2. Nama Institusi / Name of Institution Jenis Pembiayaan / Financing type

Bayaran Bulanan / Monthly Instalment : RM , , Baki Tempoh Pembiayaan / tahun bulan

Remaining Financing Tenure : /years /months

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BAHAGIAN G / PART G : Maklumat Pasangan / Spouse Details (Tidak terpakai untuk Ar-Rahnu / Not applicable for Ar-Rahnu)

Nama Penuh / Full Name

No. KP Baharu / New NRIC No. No. KP Lama / Old NRIC No. Lain-lain / Others
- -

No. Telefon Bimbit / Mobile phone No. Tarikh Lahir / Date of Birth Umur / Age Jantina / Gender
Hari/ Bulan/ Tahun/ Tahun/ Lelaki / Male Perempuan / Female
DD MM YYYY YYYY
Nama Majikan/Perniagaan / Name of Employer/Business

Jawatan / Designation Pendapatan Bulanan / Monthly Income

RM , ,

BAHAGIAN H / PART H : Pilihan Penjualan Silang / Cross-Selling Option (Tidak terpakai untuk Ar-Rahnu / Not applicable for Ar-Rahnu)
Saya berminat dengan penjualan silang (Sila lengkapkan pilihan produk penjualan silang di bawah) / I am interested in cross-selling (Please fill in your
cross selling product selection below):
Atau /Or
Saya tidak berminat dengan penjualan silang / I am not interested in cross-selling

Kad Kredit-i Bank Islam Permohonan Baharu Lain-lain

Bank Islam Credit Card-i New Application Others :
Jenis Kad / Card type Minimum PendapatanTahunan / Minimum Annual Income Visa Mastercard
Infinite Visa RM 100,000 NA
World Mastercard RM 100,000 NA
Platinum RM 48,000
Emas / Gold RM 24,000

Takaful Kemalangan Diri

Takaful Hayat / Am Lain-lain Pelan Amaun
Berkelompok Bank Islam
Plan : Amount : RM , ,
Life / General Takaful Takaful GPA Bank Islam Others :

Takaful Rumah Kandungan Rumah Lain-lain Pelan Amaun RM , ,

Home Takaful Home Content Others : Plan : Amount :

Penulisan Wasiat Wasiat Lain-lain

Will Writing Will Others :

Unit Amanah Nama Syarikat Nama Produk Amaun

Company Name : Amount : RM
, ,
Unit Trust Product Name :

Saya bersetuju dengan penjualan silang produk yang dipilih. Sekiranya permohonan pembiayaan ini diluluskan, saya membenarkan pihak Bank
membuat potongan daripada pembiayaan ini untuk pembayaran produk yang dipilih. Walau bagaimanapun, saya mempunyai pilihan untuk
membatalkan penjualan silang yang ditawarkan sebelum menandatangani surat tawaran daripada pihak Bank. Saya faham dan bersetuju dengan
semua kontrak (akad) yang dinyatakan di dalam Lembaran Maklumat Produk. / I hereby agreed with the selected cross selling product. If this financing
application is approved, I authorise the Bank to make the deduction from this financing for payment of the selected product. However, I have the option to cancel
the cross-selling offered before execution of letter of offer from the Bank. I understand and agree with all contracts (akad) mentioned in the Product Disclosure
Sheet.

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Pengakuan / Declaration

Am / General

1. Saya dengan ini memberi kuasa kepada pihak Bank untuk mendapatkan dari mana-mana pihak sebarang maklumat yang pihak Bank perlukan
untuk permohonan ini. Saya mengesahkan bahawa saya tidak bankrap dan bebas daripada sebarang tindakan kebankrapan atau tindakan
undang-undang dan mengaku segala keterangan yang tercatat di atas adalah benar dan lengkap. Saya bersetuju menerima sebarang keputusan
pihak Bank untuk menolak permohonan ini tanpa memberi sebarang sebab atau alasan. / I hereby authorise the Bank to obtain any information from
any parties as required by the Bank for the application. I confirm that I am not bankrupt and free from any bankruptcy proceedings or any legal action and admit
all information as stated above is true and complete. I agree to accept any decision from the bank to reject this application without giving any reason or excuse.
2. Bagi permohonan ini, saya mengakui dan mengesahkan bahawa saya telah membaca dan memahami segala butiran dan maklumat yang
dinyatakan di dalam Lembaran Maklumat Produk. Saya juga bersetuju tanpa syarat untuk mematuhi terma dan syarat bagi sebarang promosi
yang berkaitan dengan permohonan ini, Lembaran Maklumat Produk dan apa-apa pindaan berkaitan yang dikeluarkan oleh pihak Bank dari
masa ke semasa seperti yang dipaparkan di dalam laman web Bank Islam www.bankislam.com. / For this application, I acknowledge and confirm
that I have read and understand all details and information stated in Product Disclosure Sheet. I also agree unconditionally to comply with terms and conditions
for any promotion related to this application, Product Diclosure Sheet and any amendments issued by the Bank from time to time as displayed in Bank Islam
website www.bankislam.com.
3. Saya setuju bahawa pihak Bank berhak mengenakan caj bagi setiap perkhidmatan yang ditawarkan kepada saya pada kadar yang ditetapkan
oleh pihak Bank (seperti yang diluluskan oleh Bank Negara Malaysia) dan seperti yang ditetapkan dalam Lembaran Maklumat Produk dan pada
laman web Bank Islam. / I agree that the Bank is entitled to charge for each service offered to me at a fixed rate determined by the Bank (as approved by
Bank Negara Malaysia) and as stated in Product Disclosure Sheet and Bank Islam website.
4. Saya dengan ini mengakui bahawa saya telah membaca Notis Privasi di laman web Bank Islam www.bankislam.com dan memahami kandungannya
serta bersetuju untuk terikat dengan Notis Privasi ini. / I hereby acknowledge that I have read Privacy Notice at Bank Islam website www.bankislam.com and
understand its content and agree to be bounded by the said Privacy Notice.
Pembiayaan-i ASB / ASB Financing-i
5. Saya dengan ini membenarkan pihak Bank untuk menyemak dan mencetak unit boleh beli/unit boleh cagar di Penyata Terperinci Pelaburan Tunai
yang terdapat di sistem FDS bagi tujuan pemprosesan pembiayaan. / I hereby allow the Bank to verify and print available units for subscription/available units
for collateral in Cash Investment Details Statement which available at Fund Distribution System (FDS) for the purpose of financing processing.
Pembiayaan Hartanah Di Bawah Skim Tertentu / Property Financing Under Specific Scheme
6. Bagi permohonan pembiayaan di bawah Skim Rumah Pertamaku/Skim Jaminan Kredit Perumahan/’Priority Sector Scheme” di bawah garis panduan
Bank Negara Malaysia, saya mengaku bahawa hartanah yang akan dibiayai merupakan rumah pertama saya dan akan diduduki oleh saya sendiri. /
For financing application under the “Skim Rumah Pertamaku”/”Skim Jaminan Kredit Perumahan”/Priority Sector Scheme under the guidelines of Bank Negara
Malaysia, I acknowledge that properties to be financed is my first house and it will be occupied by me.
Takaful / Takaful
7. Saya telah dimaklumkan sepenuhnya dan faham tentang faedah perlindungan Takaful yang berkait dengan permohonan pembiayaan yang saya
pohon. Saya mengakui dan bersetuju bahawa jumlah perlindungan Takaful dan jumlah sumbangan adalah tertakluk kepada jumlah kemudahan
pembiayaan yang diluluskan oleh pihak Bank. Jika saya memutuskan untuk tidak mengambil perlindungan Takaful yang ditawarkan, saya memahami dan
bersetuju bahawa tiada perlindungan ke atas kemudahan pembiayaan sekiranya berlaku tuntutan ke atas baki jumlah pembiayaan dalam kes kematian
atau ketidakupayaan kekal. / I have been fully informed and understand about Takaful coverage benefits related to my financing application. I acknowledge and agree
that total Takaful coverage and total contribution are subject to total financing facility approved by the Bank. If I decided not to take the Takaful coverage offered, I
understand and agree that no coverage againts the financing facility in the event of a claim on the remaining amount of financng in case of death or permanent disability.
Ar-Rahnu/ Ar-Rahnu
8. Aset Gadaian sepertimana didalam akaun di atas adalah milik sah saya / I am the beneficiary owner of the asset.

Tandatangan Pemohon / Applicant’s Signature

Pemohon Utama / Main Applicant
Pemohon Bersama / Joint Applicant
Penjamin / Guarantor
Nama / Name :
Tarikh / Date :

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Untuk Kegunaan Bank / For Bank Use

Saya mengesahkan segala butiran dan dokumen di atas adalah benar semasa saya menemubual pelanggan. / I confirm all details and document above are
true while I was interviewing customer.
Saya mengesahkan pemohonan pembiayaan ini adalah berlandaskan dasar “Pengantaraan Berasasaskan Nilai”. / I confirm this financing application is
based on “Value-Based Intermediation”.

Jika ya, sila nyatakan sebab : / If yes, please state the reason :

Saya mengesahkan pemohonan pembiayaan ini adalah tidak berlandaskan dasar “Pengantaraan Berasasaskan Nilai”. / I confirm this financing application
is not based on “Value-Based Intermediation”.

Dikendalikan Oleh / Managed by : Disahkan Oleh / Verified by :

Nama / Name : Nama / Name :

Jawatan / Position : Jawatan / Position :

Cawangan / Branch : Cawangan / Branch :

Tarikh / Date : Tarikh / Date :

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PART 1: PRIVACY NOTICE IN RELATION TO PERSONAL DATA PROTECTION (“PRIVACY NOTICE”)

This Privacy Notice relates to the personal information Bank Islam Group (referred to as “the Bank” / “we” which shall
include Bank Islam’s holding company(s), subsidiaries, associated companies, affiliates, representatives and branch offices)
collects in relation to the products and services we offer (referred to as “Facilities”) to you. This Privacy Notice is intended to
be addressed to, without limitation, individual customers, individuals in body corporate / business enterprise (e.g directors,
shareholders, managers, authorized signatories and persons and company secretary), beneficial owners (e.g. sole proprietor,
partners and joint names), guarantors and obligors (referred to as “Identified Individuals” / ”you”). This Privacy Notice
explains the types of personal information we collect from all Identified Individuals for the Facilities you are enjoying, you
have requested, you intend to request and further explains how the information is processed, used, protected and stored.
Your application and continued usage of our Facilities shall be deemed as your consent for the Bank to continue collecting,
use, process and store your personal information. Please review our detailed Privacy Notice prior to providing us your
personal information. If you are reading and signing this Privacy Notice on behalf of body corporate / body enterprise and the
beneficial owners, you shall undertake to ensure all Identified Individuals understand and agree to the Privacy Notice.

TYPES OF YOUR PERSONAL INFORMATION WE COLLECT AND HOW WE USE YOUR PERSONAL INFORMATION
The personal information we collect from you in relation to our Facilities that you have requested or requested by others
whose obligation is guaranteed by you, or whom you represent and are authorized to act on behalf of you, or whom you are
associated with, shall be deemed willfully provided by you.
The personal information we collect from you in relation to the Facilities includes but not limited to:
Full name Identification number Date of birth Gender
Race Religion Citizenship / residency Marital status
Spouse name Number of dependents Occupation Employer
Annual income Financial information Tax details Education
Contact details (such as address, phone number, email address)

The Bank may also collect your personal information from other sources, including but not limited to regulatory bodies,
supervisory authority, credit bureaus, credit reporting agencies, financial crime reference agencies, your employer, your
guarantors and from other sources which the Bank has access to.

FAILURE TO SUPPLY YOUR PERSONAL INFORMATION

The supply of your personal information to the Bank is necessary in connection to the provision of the Facilities we offer.
Failure to supply such information may result in the Bank being unable to provide you the Facilities and / or failure to comply
with regulatory requirements.

PURPOSES FOR COLLECTING YOUR PERSONAL INFORMATION

The purposes (“Purpose”) for which your personal information are collected and processed depends on the nature of the
relationship which you as a data subject have with the Bank. Broadly, the Purpose may comprise part or all of the followings:-
i. the processing of the Facilities you are currently enjoying and / or the Facilities you have requested;
ii. for prevention and detection of financial crime (including, without limitation, money laundering, and fraud prevention,
detection and prosecution);
iii. notifying you on the important changes to the features of the Facilities;
iv. to support the operational activities of the Facilities;
v. updating and managing the accuracy of the data you have provided the Bank;
vi. the enforcement of your obligations to the Bank within the provision of the Facilities, including the collection and recovery
of amounts outstanding from you or obligated upon you;
vii. determining your credit worthiness and maintaining your credit history for present and future references. This includes,
but is not limited to checking your CCRIS and any other credit reporting agencies under Credit Reporting Agencies Act
2010 (CRAA 2010)
viii. determining the amount of indebtedness owed by you / to you and designing improved financial solutions for you;
ix. assessment and analysis including credit / lending / insurance risks / behaviour scoring / product analysis and market
research;
x. as required by any law or regulation;
xi. communications and ensuring customer satisfaction, which may include conducting surveys to improve the quality of the
Facilities, responding to inquiries and complaints and to generally resolve disputes; and
xii. protecting Bank Islam Group’s interest and other ancillary and / or related purposes.
xiii. performing an employment check with the personnel empowered to give such confirmation in your organisation.

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DISCLOSURE OF YOUR PERSONAL INFORMATION

The Bank will not reveal your personal information including your address, telephone number or email address to any
external party other than parties listed below (the “Authorized Parties”) other than for the Purpose above, unless the Bank
has your permission, or is under either a legal obligation or any other duty to do so:-
a) any officer, employee, agent or director of the Bank

b) relevant third parties such as professional advisers, strategic business partners and alliances, service providers,
insurers / Takaful operator or insurance / Takaful brokers, outsourced agents, merchants, vendors, business partners
and business agents who supports the operational activities of the Bank and whom are under legal obligation to the
confidentiality of your information;
c) any actual or potential participants or assignee, novatee or transferee of the Bank’s rights and / or obligations under
any transaction between the Bank and you (or any agents or professional advisers);
d) any rating agency or direct / indirect provider of credit protection to the Bank;

e) any party as required by any law or any government, quasi-government, administrative, regulatory / supervisory
body or authority, court or tribunal;
f) any credit reference agency that the Bank uses for credit assessment or credit review of you and parties related to
the facilities provided by the Bank to you;
g) any financial crime references agencies, other financial institution and any of their respective agents;

h) any security party, guarantor or collateral provider for your facilities.

i) any parties who the bank seeks employee reference from.

The above disclosure is subject at all times to any laws (including regulations, standards, guidelines and / or obligations)
applicable to the Bank. In addition, this Privacy Notice serves as a consent for any credit reporting agency to disclose your
credit information to the Bank pursuant to section 24(1)(a) of the CRAA 2010.
TRANSFER OF YOUR PERSONAL INFORMATION OUTSIDE MALAYSIA
The Bank may transfer your personal information outside of Malaysia if any of the Bank’s service providers are located in
countries outside Malaysia. Such transfers for the purpose are necessary to perform or conclude the Bank’s services to you, to
perform or conclude the Bank’s contract(s) with the relevant third parties, and for legal proceedings or obtaining legal advice.
Should the operational need arise where your personal information is to be processed, used, transferred to, or stored at a
location outside of Malaysia, the Bank will take necessary steps to ensure that your personal information is treated securely
and any service providers engaged by the bank are contractually bound to not use your personal information for any reasons
other than what they are contracted to provide and is in accordance to this Privacy Notice and the respective jurisdictions’
personal data laws. In these regards, you give your consent to us transfer to your personal information outside Malaysia.
RETENTION OF YOUR PERSONAL INFORMATION
Information provided by you shall be retained as long as the Purpose for which the information was collected continues to
exist; destruction / permanent deletion of data will be made once the purpose information collected has ceased permanently
unless it is to be retained to meet any legal and / or regulatory requirements or to protect the Bank’s legitimate interest.

THIRD PARTY DATA / INFORMATION

Where you shall be required and have provided the personal information relating to others including that of co-applicant(s),
spouse, related parties, contact person, referees, and employer’s (including, but not limited to from Suruhanjaya Syarikat
Malaysia (SSM) and any credit reporting agency governed by CRAA 2010) for the Purpose, you shall undertake and be
deemed that you have obtained their consent or that you are entitled to provide their information to the Bank.

DIRECT MARKETING OPTION

The Bank would like to contact you to keep you informed of our latest products and services, other products and services
offered, marketing campaigns, advertisements and promotions including those jointly run with our current and future
partners and affiliates (referred to as “direct marketing”). Hence, the Bank will use your contact details including your
address, telephone numbers and email address for the purpose of direct marketing activities including the administration of
offers and competitions.

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In case you do not wish to be contacted for direct marketing activities, you may opt out via telephone, post or email our
Contact Centre:
Bank Islam Contact Center & Customer Care
Level 17, Menara Bank Islam
No. 22, Jalan Perak
50450 Kuala Lumpur
Telephone: +603 26 900 900
E-mail: contactcenter@bankislam.com.my
Please be informed that we will process your request within 3 months from the date of your request.

ACCESS AND CORRECTION TO YOUR PERSONAL INFORMATION

You have the right to request access to your personal information held by the Bank. The Bank may charge you a nominal fee
for such request. You may also update and correct your personal information held by the Bank. For such request, you may
visit any of our branches or you may speak to our Contact Centre & Customer Care agents at the given address. You will be
required to fill in the ‘Data Access Request’ form or ‘Data Correction Request’ form available at our branches.

HOW TO CONTACT US
If you have any questions concerning this Privacy Notice, you may visit any of our branches which location you can obtain
from our website or you may call our Contact Centre & Customer Care or write to the Bank, at the given address. You may
also contact us to convey your complaints relating to this Privacy Notice or otherwise relating to any misuse or suspected
misuse of your personal information.

CHANGES TO THIS PRIVACY NOTICE

The Bank reserves the rights to amend this Privacy Notice at any time and will place notice of such amendments on the
Bank’s website and / or the Bank’s branches and / or via such other suitable methods. This Privacy Notice is not intended to,
nor does it, create any contractual rights / nor any contractual obligations on the Bank or any other party or on behalf of any
party. Any references made to ‘privacy statement’ in any of the Bank’s documentation, refers to this ‘Privacy Notice’.

PART 2: ACKNOWLEDGEMENT OF PERBADANAN INSURANS DEPOSIT MALAYSIA (PIDM) NOTIFICATION

PIDM COVERAGE
I / We have been notified that:
Money paid and placed into deposit account is protected by PIDM.
Money paid and placed into investment account is not protected by PIDM.
A copy of PIDM brochure has been provided to me.

I hereby acknowledge that I have read this Privacy Notice and understand the content and agree to be bound by this
Privacy Notice. I hereby explicitly consent that for financing applications the Bank can contact the relevant personnel to
conduct my employment verification.

Signature :

Name :

I.C. No :

Date :

Position :

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Tarikh : ……………………………….

Bank Islam Malaysia Berhad (98127-X) (Bank Islam)

Tuan / Puan,

KEBENARAN KAKITANGAN UNTUK POTONGAN / PINDAHAN GAJI BAGI BAYARAN ANSURAN

BULANAN KEMUDAHAN PEMBIAYAAN PERIBADI-i BANK ISLAM MALAYSIA BERHAD (KEMUDAHAN
PEMBIAYAAN )

Merujuk kepada perkara di atas, saya dengan ini bersetuju untuk mematuhi terma dan syarat Kemudahan
Pembiayaan-i saya di Bank Islam iaitu:
 Potongan Gaji - Bank Islam akan berurusan dengan Jabatan Sumber Manusia majikan saya untuk
membuat potongan gaji bulanan saya dan seterusnya memindahkan amaun ansuran bulanan tersebut
ke Bank Islam.

 Pindahan Gaji – Saya memberi kebenaran kepada Bank Islam untuk berurusan dengan Jabatan
Sumber Manusia majikan saya bagi memaklumkan keperluan pindahan gaji. Saya juga akan membuat
permohonan dan memberi kebenaran kepada Jabatan Sumber Manusia untuk memindahkan akaun
gaji saya ke Bank Islam dengan serta merta.

Saya bersetuju bahawa akujanji ini akan berkuatkuasa dalam tempoh 60 hari dari tarikh Surat Tawaran
Kemudahan Pembiayaan dan akan berkuatkuasa sehingga tarikh penyelesaian Kemudahan Pembiayaan atau
pada tarikh tamat perkhidmatan saya sebagai kakitangan kepada majikan saya, yang mana terdahulu.
Sekiranya potongan gaji atau pindahan gaji gagal dilaksanakan, Bank Islam berhak untuk menukar kadar
keuntungan istimewa yang ditawarkan di bawah Skim Pakej kepada kadar bukan pakej.

Saya juga dengan ini bersetuju dan memberi kebenaran kepada Bank Islam untuk menyalurkan maklumat
berkaitan akaun pembiayaan saya dengan Bank Islam kepada Jabatan Sumber Manusia majikan saya atau
majikan saya yang baru, pada bila-bila masa perlu.

Kebenaran ini berkuatkuasa dari tarikh Surat Tawaran Kemudahan Pembiayaan iaitu pada (tarikh)

Sekiranya saya menamatkan perkhidmatan atau bersara awal dari majikan saya ini sebelum tamat tempoh
pembayaran Kemudahan Pembiayaan, saya bertanggungjawab untuk memaklumkan kepada Bank Islam tentang
penamatan perkhidmatan atau persaraan awal tersebut dan akan meneruskan bayaran Ansuran Bulanan sendiri
atau membuat penyelesaian awal bagi Kemudahan Pembiayaan tersebut. .

Terima kasih.

Yang benar,

………………………………......................
Nama: ……………………………………….
No. Kakitangan: …………………………….
No. Kad Pengenalan:................................
No.Telefon: ............................................
Jabatan: ……………………………
PRODUCT DISCLOSURE SHEET
Please read this Product Disclosure Sheet before you
decide to participate in the Group Personal Accident
Takaful – PA Bank Islam.

Please be sure to also read the general terms and Takaful GPA Bank Islam
Date: 15 August 2022
conditions.

1. What is this product about?

The product is exclusively designed for all personal and home financing customers of Bank Islam Malaysia Berhad
(“BIMB”) that provides twenty-four (24) hours a day and worldwide coverage for bodily injury resulting in death,
permanent disability or injury caused solely by a sudden and unforeseen accident.

Under this product, BIMB will appoint Syarikat Takaful Malaysia Am Berhad (“Company”) as the agent to manage
the Group Takaful Fund (GTF). Accordingly, the customers will authorize BIMB to manage the contribution amount
paid for the purpose of this Group Personal Accident (GPA) Takaful Plan.

2. What are the Shariah concepts applicable?

This product applies the following Shariah concepts:

1. Tabarru’ means donation for charitable purposes. Under this product, the participant donates a portion of
the contribution to the General Takaful Fund (GTF) to help other participants.
2. Wakalah refers to a contract where a party, as principal authorizes another party as his agent to perform a
particular task on matters that may be delegated, with or without the imposition of a fee. Under this product,
the participant authorizes the Company to manage the GTF and in return, the Company will receive a wakalah
fee.
3. Ju’alah refers to a contract where a party offers a specified reward to another party who achieved a
determined result. Under this product, the participant allows the Company to receive a portion of
distributable surplus arising from the GTF as performance incentive for the Company’s achievement in
managing the GTF which results in the surplus.
4. Qard refers to a contract of lending money by a lender to a borrower where the latter is bound to repay an
equivalent replacement amount to the lender. Under this product, the Company will lend an amount of money
to the GTF without interest if the GTF is in deficit.

3. What are the covers / benefits provided?

BENEFITS (DUE TO ACCIDENT) LIMIT PER EVENT/ PER YEAR (RM)

1. ACCIDENTAL DEATH OR PERMANENT DISABLEMENT 100, 000

2. MEDICAL EXPENSES 4,000
3. REPATRIATION EXPENSES 3, 000
4. FUNERAL EXPENSES 3, 000
5. DAILY HOSPITAL INCOME (UP TO 30 DAYS PER YEAR) RM75 PER DAY
6. AMBULANCE FEES 200
7. SNATCH INJURY 1,000
8. PURCHASE OF ORTHOPEDIC EQUIPMENT 1,000
9. BADAL HAJI 3,000

Note: Duration of cover is three (3) years from the effective date as per declaration listing provided by BIMB to
the Company.

Page 1 of 4 STMAB/PDS(E)/GPA-BIMB 3 YEARS /V01/03-2022

4. How much contribution do I have to pay?

The total contribution that you have to pay is RM330.00* for a duration of three (3) years Period of Takaful.
*Including Service Tax.

5. What are the fees and charges that I have to pay?

Type Amount
Wakalah Fees 55% of contribution of which:
- Commission – 25%
- Other expenses – 30%
Stamp Duty (for Master Certificate payable by BIMB) RM10.00
Service Tax 6% of the contribution paid

6. What are some of the key terms and conditions that I should be aware of?

Some of the key terms and conditions that you should be aware of are:

 Duty of disclosure
Consumer Takaful Contract
Pursuant to Paragraph 5 of Schedule 9 of the Islamic Financial Services Act 2013, if you are applying for this
takaful wholly for purposes unrelated to your trade, business or profession, you have a duty to take reasonable
care not to make a misrepresentation in answering the questions in the Proposal Form (or when you apply for
this takaful). You must answer the questions fully and accurately. Failure to take reasonable care in answering
the questions may result in avoidance of your contract of takaful, refusal or reduction of your claim(s), change
of terms or termination of your contract of takaful. The above duty of disclosure shall continue until the time
your contract of takaful is entered into, varied or renewed with us. In addition to answering the questions in
the Proposal Form (or when you apply for this takaful), you are required to disclose any other matter that you
know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied.
You also have a duty to tell us (through BIMB) immediately if at any time after your contract of takaful has
been entered into, varied or renewed with us any of the information given in the Proposal Form (or when you
applied for this takaful) is inaccurate or has changed.
 Change in Risk - you must inform us (through BIMB) of any material changes during the certificate period so
that the necessary amendments are endorsed into your certificate.
 Age limit - This Certificate does not cover any person under the age of eighteen (18) years or over the age of
sixty- five (65) years.
 Limit of liability in respect of all persons covered travelling in the same conveyance or per event shall not
exceed RM5,000,000.00.

Note: The above list is non-exhaustive. Please refer to the Certificate Wordings for the full list of terms and
conditions under this product.

7. What are the exclusions under this product?

This product does not cover the followings:

1. Death or Disablement or any other loss caused directly or indirectly by:

(a) war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion,
revolution, insurrection, mutiny or usurped power, strike, riot, civil commotion, military or popular
uprising, when the Person Covered(s) is/are taking part therein
(b) insanity, suicide (whether sane or insane), intentional self-inflicted injuries or any attempt thereat;
(c) effect or influence of drugs or alcohol;

Page 2 of 4 STMAB/PDS(E)/GPA-BIMB 3 YEARS /V01/03-2022

 (d) pre-existing physical or mental defect or infirmity; or
(e) provoked murder or assault.
2. Death or Disablement or any other loss sustained by the Person Covered:
(a) while travelling in an aircraft as a member of the crew, except only as a fare-paying passenger in an
aircraft licensed for passenger service; or
(b) while committing or attempting to commit any unlawful or criminal act.
3. whilst participating in professional sports and/or hazardous activities including but not limited to hunting,
mountaineering, ice-hockey, polo playing, steeple chasing, winter sports, yachting, caving, potholing, white-
water rafting, sky diving, cliff diving, bungee jumping, water-ski jumping, under-water activities involving
the use of breathing apparatus, martial arts or boxing, aerial activities such as parachuting, paragliding and
hand-gliding or participation in any form of race or competition other than on foot;
4. individuals such as pilots, aviation crews and firemen, personnel in the armed forces, any law enforcement
forces and policemen during the course of their work or whilst on duty, fishermen, professional motor
racers, professional sportsmen, stevedores, building demolition workers, divers, jockeys, logging workers,
miners, marine salvage crew, individuals directly involved in making or handling explosives, tree fellers,
window cleaners of high‐rise buildings and other hazardous and dangerous occupations;
5. Nuclear energy or radioactivity of any kind including but not limited to ionising radiations from or
contamination by radioactivity from any nuclear fuel or from any nuclear waste or from the combustion of
nuclear fuel or nuclear weapons material;
6. This certificate does not cover claims as a result of Epidemics and / or Pandemics as declared by the World
Health Organization or any governmental authority in Malaysia.

8. Can I cancel my certificate?

You may cancel your certificate by notifying BIMB. Upon approval by BIMB, you may proceed for cancellation by
giving us a written notice and BIMB’s approval letter. Upon cancellation, you are entitled to a partial refund of the
contribution as per table below provided you have not made any claim.

Cancellation in Refund based on

Year 1 - Prorated for year 1 and
- Full refund for year 2 to 3
Year 2 - No refund for year 1
- Prorated for year 2 and
- Full refund for year 3
Year 3 - No refund for year 1 and 2 and
- Pro-rated for year 3

9. What do I need to do if there are changes to my contact details?

It is important that you inform us of any changes in your contact details to ensure that all correspondences reach
you in a timely manner. Please contact any of BIMB branch for assistance.

10. Where can I get further information?

Should you require additional information or wish to view the Certificate Wordings about this product, please
contact:

Bank Islam Malaysia Berhad

Level 32, Menara Bank Islam
No. 22, Jalan Perak
50450 Kuala Lumpur
Tel : +603 26 900 900
Email : contactcenter@bankislam.com.my

Page 3 of 4 STMAB/PDS(E)/GPA-BIMB 3 YEARS /V01/03-2022

11. Other types of similar cover available.

Please refer to our branches or agents for other similar types of cover available.

IMPORTANT NOTE:

“CUSTOMER” REFERS TO PERSONAL OR HOME FINANCING CUSTOMER OF BIMB WHO ENROLL AND
PARTICIPATE IN THIS PRODUCT.
“COMPANY” REFERS TO SYARIKAT TAKAFUL MALAYSIA AM BERHAD.

YOU ARE ADVISED TO NOTE THE TABLE OF BENEFITS FOR DEATH AND DISABLEMENT DUE TO ACCIDENT IN
YOUR CERTIFICATE AND MUST NOMINATE A NOMINEE AND ENSURE THAT YOUR NOMINEE IS AWARE OF THE
CERTIFICATE THAT YOU HAVE PARTICIPATED.

YOU SHOULD READ AND UNDERSTAND THIS PRODUCT AND DISCUSS WITH BIMB OR CONTACT US DIRECTLY
FOR MORE INFORMATION.

Syarikat Takaful Malaysia Am Berhad is licensed under the Islamic Financial Services Act 2013 and regulated by
Bank Negara Malaysia.

The information provided in this disclosure sheet is valid as 15 August 2022.

Declaration by the Customer

In addition to the information provided in this Product Disclosure Sheet, I shall refer to the Certificate Wordings and
Individual Certificate for the terms and conditions, and hereby agree on my enrolment in this product.

____________________________
Name:
NRIC No:
Date:

Witnessed by (BIMB’s personnel)

___________________________
Name:
BIMB Branch:
Designation:
NRIC No:
Date:

Page 4 of 4 STMAB/PDS(E)/GPA-BIMB 3 YEARS /V01/03-2022