1Policy Owner
2Insured
33rd Party
4Witness
5Credit Card
6EPP
7Signature
8Generate
Policy Owner - details
Insured - details)
Tick here if Policy Owner and Insured is same person
3rd Party Payor - details
Tick here ONLY if there is a 3rd Party Payor
/
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Select all that apply
Select all that apply
Correspondence Address: Tick here if same as Policy Owner
Witness - Basic Information
Credit Card - Basic Information
Type 4 digits per box. Paste full 16-digit number — it will auto-split.
Request For
Yes! I wish to pay insurance premium through recurring credit/debit card service and agree to abide by the Terms & Conditions as specified overleaf.
Notice on Personal Data and Privacy
I have read the Company’s Notice on Personal Data and Privacy and hereby consent to the processing of my personal data in
accordance with the Company’s Notice on Personal Data and Privacy as set out in the Company’s website
(https://www.manulife.com.my/en/individual/privacy-policy.html).
EPP Options
Follow payment fequency in PI
Signed at/ Signed on
Signature of Card Holder
Tap to Sign (Card Holder)
Signature of Policy Owner
Tap to Sign (Policy Owner)
Signature of Witness
Tap to Sign (Witness)
Credit Card Enrolment
LF4092 · 4 Pages (email to MYNB)
Zero Interest Easy Payment Plan
LF1739 · 2 Page (email to MYNB)
Amendment to Application
LF1042 · 1 Page (upload into EPOS)
Secured Session Active: This platform operates on a static, local-injection framework. We do not store, log, or track any personal details or financial credentials on external servers.