Student Takaful Application

Full Name

IC No.

Gender

Date of Birth:

Date of Birth

Tel

Institution

Course

Contribution

Contribution Table Guide:
Course Period	Total Contribution
1 Year	$20.25
2 Years	$40.25
3 Years	$60.25
4 Years	$80.25

(Contribution includes stamp duty amounting $0.25)

Akad

I, hereby agree to participate in Student Personal Accident Takaful Scheme offered by Insurans Islam TAIB General Takaful Sdn Bhd with the selected total contribution for the period coverage of the total no. of course year.