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Friday July 30 2010

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April 27, 2010

Dawood Family Takaful Limited and VesPk signed Takaful Agreement

November 25, 2009

Interview with FM-107- Mufti Munib Ur Rehman; Chairman Shariah Board, Dawood Family Takaful Ltd and Dr Bakht Jamal Shaikh; Head Of Operations Dawood Family Takaful Ltd

November 23, 2009

Exclusive Interview with The Financial Daily- Abdul Halim Nasri Chief Executive Officer, DFTL

October 26, 2009

RAMAZAN CONTEST - 2009

August 23, 2009

DFTL Brand Recognition Compaign

Home > Individual Form

FAMILY TAKAFUL PROPOSAL FORM

For Office Use Only		Proposal No


Master Contract No		Certificate No

INSTRUCTION FOR FILLING IN PROPOSAL FORM

	Please complete all sections of Proposal Form in CAPITAL LETTERS. Write Yes or No or in BOX where applicable.
	Benefits IIIustrations and Brochure will also be given together with the Proposal Form.
	All information must be declared truthfully with Utmost Good Faith, as required by relevant Laws.

A. DETAILS OF LIFE PROPOSED ("PARTICIPANT")

1. Salutation Mr.,Mrs, Ms, Miss, Dr.

2. Are you Pakistani Citizen

Yes No

Please Specify if No:

3. Full Name

4. Father/Husband Name

5. CNIC/OLD NIC/Passport No.

6. Gender:a) Male	b) Female
Date Of Birth	- -

8. Age

9. Marital Status:- a) Single

b) Married

c) Divorced

d) Widowed

10. Religion:- a) Islam

b) Other

If other, Please specify:

11. Monthly Income

(PKR)

12. Occupation

13. Exact Nature of Work

14. Name of Employer

B. CORRESPONDENCE ADDRESS

1. Residential Address		2. Office Address


City		City

Post Code		Post Code

Province		Province

3. Preferred Mail Address a) Residential b) Office		4. E-Mail Address

5. Residential Phone No		6. Office Phone No

7. Mobile No		8. Fax No

C. PAYMENT DETAILS

1. Frequency:

(i) Yearly
(ii) Half Yearly
(iii) Quarterly
(iv) Monthly

2. Payment thru:

(i) Cash
(ii) Credit Card
(iii) Cheque
(iv) Salary Dead.

3. Payer:

(i) Self
(ii) Spose
(iii) Parent
(iv) Employer

4. Bank Account
Details:

(i) Bank
(ii) Branch
(iii) No

5. UNIT LINK Plan(s) only:

	Type	%
(i) Growth
(ii) Balance
(iii) Income
Indexation if Yes tick

Note:- If payer is other than self, then please complete Part-J of Proposal Form.

D. PLAN DETAILS

Note: The Proposer is advised to study the Product iIIustration and Brochures carefully, in particular to those benefits which are guaranteed and those which are only expected. Attachment of Rider(s) is optional, the Proposer may choose to add these benefits by payment of and additional contribution.

1) Basic Plan	a) Product Code	b) Term (Years)	c) Sum Cover	d) Contribution


2. Supplimentry Riders
a)Accidental Death OR Death & Disability Benefit	ADB / ADDB
b) Critical Illness Benefit	CIB
c) Total Permanent Disability OR Waiver of Contribution	TPD / WOC
d) Family Protection Benefit	FPB
e) family Income Benefit	FIB
f) Funeral Expenses Benefit	FEB
g) Other

Total Contribution

E. RISK ASSESSMENT INFORMATION

1. Nominee:- a)Name:-		b) Age:-
c) Relationship:-		d) CNIC

2. Guardian Particulars (if nominee is minor):-		a) Name:-
b) Age:-		c) Relationship:-

3. Automatic Non Forfeiture Option:- (A) Paid Up
(B) Takaful Extension		(C) Cash Surrender

4. Current insurance/Takaful in force and application(s) pending with us or other Companies on the life of Participant?

a) Certificate / Application No.	b) Company	c) Amount of Death Benefit	d) Amonut of Accidental Benefit	e) Date of Issue/Submitted	f) Standard/ Substandard

Yes/No

During the latest Past 5 Years, have your ever stayed for more than 1 month in a country diffrent from your usual place of residence? If yes, give the detail of stay for more than 30 days and reason.

Are you now or were you ever been a member of any military force?

Are you now engaged or intend to engage in any private flying, hazardous sports, hazardous pastime activity or race?

Has any application or reinstatement of life insurance/Takaful, critical illness, health or accidental insurance/Takaful on your life ever been declined, postponed, rated up or in any way modified by this Takaful Operator or any other company?

Please state whether this application is to replace or intended to replace any existing Certificate with this Takaful Operator or other companies?

F. PARTICIPANT HEALTH DETAILS

1. Have you ever been suffering, told, investigated, diagnosed or treated for:

Yes / No

(a)

Asthma, Tuberculosis or any other respiratory, or lung disease?

(b)

Palpitation, Chest Pain, difficulty in breathing, heart attack, High Blood Cholesterol or any other disease of heart?

(c)

Peptic Ulcer, Gastritis, pain in abdomen or any other disease of stomach or intestine?

(d)

Jaundice, Hepatitis, any other Liver, Pancreas or Gall bladder disease or been a Hepatitis-B or Hepatitis-C carrier?

(e)

Protein, Blood in urine, kidney stones or any disorder of urinary system?

(f)

Epilepsy, Fever fits, Paralysis, Stroke, Mental Disorder, or any disease of the brain or nervous system?

(g)

Diabetes Mellitus, Sugar in Urine, Goiter or any disease of the Thyroid or other metabolic Disease?

Have you ever been suffering, told, investigated, diagnosed or treated for:

(h)	Cancer, Tumor, cyst or any swelling?
(i)	Sexually transmitted disease?
(j)	Enlarged lymph nodes, rheumatic fever, severe skin disease, anemia or any other blood disorder?
(k)	Arthritis, Gout, disorder of the spine, back bones, joints, or muscles?
(l)	Severe injury to any parts of the body or any other illness not mentioned above?
(m)	Have you/Your spouse ever received medical advice, been tested for HIV or treated for AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex)?
(n)	Have your anytime in the past 3 months, had continuous and and unexplained symptoms of Fatigue or tiredness, diarrhea, weight loss, loss of appetite, enlarged lymph nodes or unusual skin lesions?
(o)	Have you ever been refused as a blood donor or ever received any blood transfusions or blood products?

2. During PAST FIVE YEARS, have you had gone for:

(a)	Diagnostic tests such as X-ray, electrocardiogram, Urine/ Blood test, ultra sound, mammogram, or biopsy etc?
(b)	Surgical Operation, medical advice or hospital admission/ treatment due to any reason mentioned or not mentioned above?
(c)	Have you ever met with any accident? If yes, Please gives details.

3. For FEMALE only

(a)	Are you now pregnant? If “Yes”, since how many months?
(b)	Have you ever had disease of the breast, female organs, menstrual disorders, abnormal result of pap smear test or complications at child birth?

4. Have any of Your family members (i.e. spouse, father, mother, sister, or brother) ever had or been told to have any diseases, illness, impairments mentioned
or not mentioned above?

5. Please fill the family tree

	ALIVE		DEAD
	Age	Health Status	Year of Death	Age at Death	Cause of Death
Father
Mother
Brother / Sister
Wife / Husband
Children

10. Religion:- a) Islam

b) Other

If other, Please specify:

G. PARTICIPANT HEALTH DETAILS

State Your:
6. (a) Height (cm)		(b) Weight (kg)
(c) Chest Measurement (cm)		(d) abdoment Measurement (cm)
(e) Any Weight increase/decrease during past ony year (kg)		Reason for the weight change:-

7. (a) Do you smoke for the past 1 year?		(b) If Yes, since when, what & Quantity per day:
8. (a) Do you Consume alcohol, habit forming drugs or narcotics?		(b) If Yes, specify name, quantity and duration:
9. Have your ever used any of habit forming drugs Or narcotics or been treated for alcoholism or drugs habits?		10. Do your have any birth defect, physical deformity or disability?
11. ARE YOU NOW IN GOOD HEALTH.		If No, Please describe.

AGENT DECLARATION

I do hereby declare that I personally met proposer and all information contained in the application form is the only information given bye the applicant and I have neither withheld any information which might influence tha acceptance of this application, nor given any advice to the applicant contrary to the provisions contained in the standard certificate issued bye Dawood Family Takaful Limited.


Agent Name		Agnet Signature
Agent Code: Unit Code: Tel No:

H. "AQAD" BY PARTICIPANT

I do hereby that all statements made above and other documents submitted in connection with this application are complete and true to my knowledge and belief. I assent and authorize Dawood Family Takaful limited (herein after known as Takaful Operator to seek medical information from my doctor(s) who at any time have attended me or from any hospital or organization that has any records or knowledge of my health. A photocopy of this AQAD shall be as effective and valid as the original. I agree that this declaration and all statements made above shall form the basis of the Takaful contract between me and the Takaful operator and they are deemed to be incorporated in the contract.

I also agree that if any untrue statement(s) be contained therein, the contract of Takaful herewith shall be absolutely null and void. I agree that my Takaful Contribution shall be placed in the Participant Investment Account (PIA) and/or WAQF/Participant Takaful Fund (PTF), as per allocation determined by the Takaful Operator and the Takaful Operator shall manage and invest PIA and WAQF to the expertise of the Takaful Operator and in accordance with Shariah. In return, I agree to allow the Takaful Operator to deduct a certain percentage from the WAQF (PTF) as Wakala fee. I further agree that a portion of my contribution be allocated as Tabamu (donation) in to the WAQF fund and be used to help other Participants in time of misfortune. The PIA shall be invested by the Takaful Operator and the profit/loss arising out of his investment, if any, shall be credited to my PIA. The Takaful Operator shall be entitled to Fund Management Fee (Wakala Tharawat Fee) from the PIA as stated in the Product Illustrations. I also agree that the net surplus arising from the WAQF, if any, shall be managed by the Takaful Operator according to the method and allocation approved by the Appointed Actuary in accordance with Shariah Principle that will benefit the Participants.

I further agree to allow the Takaful Operator to manage and utilize my PIA fund in the event of non- payments of Contribution after the passage of stipulated Grace Period for the continuation of coverage benefits and keep Certificate in force during such time subject to the Takaful Operator terms and conditions. I further declare that all my declaration on made herein and me statements or answers in this application or in any required questionnaires or documents by the Takaful Operator or amendments together with the Certificate shall constitute the entire contract between the parties. I have also not given any other information, except those written in this application form to the mentioned agent.

If any cancellation of Proposal received after Medical Check-up has been done, I agree to allow the Takaful Operator to deduct any medical expenses incurred by the Takaful Operator from the Contribution paid. I also authorize Takaful Operator to send messages to my given mobile number and emails at my email address.


Signature of Life proposed		Signature of payer (if other than life proposed)

Date and Place		Date and Place


name:		name:
N.I.C No:		N.I.C No:
Date:		Date:

I. AGENT DECLARATION

I do hereby declare that I personally met life proposed and all information contained in the application form is the only information given bye the applicant and I have neither withheld any information whick might influence the acceptance of this application, nor given any advice to the applicant contrary to the provisions contained in the standard certificate issued by Dawood Family Takaful Limited. I do hereby certify that build measurements and weight also checked by me and found the same as mentioned above. If any request for cancellation of Proposal received after Medical Check-up has been done and no payment made, I do hereby agree to allow the Takaful Operator to deduct any medical expenses incurred by the takaful operator from my commission


Agent Name		Agnet Signature
Agent Code: Unit Code: Tel No: