SECTION A (BIO DATA)Surname Other names Sex - Select -MaleFemaleMarital Status - Select -SingleMarriedDivorcedWidowedDate / Time Occupation Residential Address Phone/Mobile Email Commencement Date Type of Plan - Select -Educational PolicyHajj & Umrah Family TakafulComfort Family TakafulGroup Family TakafulConflux Family TakafulTenure Sum Covered Takaful Instalments Supplementary Benefit (if any) Mode of Payment - Select -YearlyHalf YearlyQuarterlyMonthlySECTION B (BENEFICIARIES)How many beneficiaries? - Select -1234Full Name Age Percentage Relationship Full Name Age Percentage Relationship Full Name Age Percentage Relationship Full Name Age Percentage Relationship SECTION CAre you currently suffering from any form of illness, impairment or physical disability? Yes NoMedical Report Choose File Your Height (meters) Your Weight (kg) Upload Utility Bill Choose File Upload ID Card Choose File Signature Method I want to sign online with my finger I want to upload my signatureSignature Sign Here Signature Upload Choose File Submit Form