Awatra Sdn Bhd

Unit D-3A-3A & D-3A-05

Level 3A, Menara Mitraland
13A, Jalan PJU 5/1, Kota Damansara
47810 Petaling Jaya
HP: +60.1.8319 1482
T: +60.3.7628 4590
F: +60.3.7628 4587
W: www.awatra.com
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HOSPITALIZATION & SURGICAL INSURANCE (GHS) FORM

1. EMPLOYEE PERSONAL DETAILS

Employee Name: _SAIFUL RIZAL BIN ZAKARNA___________________________________________________________________

NRIC No : _____781004-03-5193_____________________________ Marital Status : ___MARRIED_________________________

Position/Designation : ________QA/QC MANAGER____________________ Department : ____________________________________

Mobile No:_____013-7761978____________ Email : ____saifulrizal.zakarna@petronas.com.my______________________________

2. DEPENDANT DETAILS (SPOUSE & KIDS)

Note:
1. “Insured Person” shall mean the person described in the Policy Schedule including his/ her Dependant (if applicable).
2. “Employee’s Dependants” shall mean:-
a) Legally married 1st spouse.
b) Unmarried children over 30 days old but under nineteen (19) years of age or twenty-four (24) years of age is still on full-time
higher education, and who are not gainfully employed.
3. “Child” shall mean any person who has attained the age of 30 days and is unmarried person, is financially dependent upon the
insured and is under the age of 19, or up to the age of 23 for those registered as full time students at a recognized educational
institution.
4. “Spouse” shall mean your legally married wife or husband named in the Policy Schedule, for the purpose of this policy, a common
law marriage is not considered a legal marriage except as provided under the law Reform (Marriage & Divorce) Act 1976, For
marriage in accordance to Islamic Law the term “Spouse” is limited to one (1) Spouse as named in the Policy Schedule.

Relationship (i.e. Spouse, Children,

Dependant details (Spouse & Kids) NRIC No.
etc.)
ZAINUN TUKIMAN 780512-01-5442 SPOUSE

MUHAMMAD UMAR IQBAL 061028-01-0227 CHILDREN

SAIDATUL UZMA 081201-01-0764 CHILDREN

Please attached a copy of NRIC/ each

Ref No. : Petronas - MSC - CTC/HC-HRM/2018/254 (01/07/19)