Policy No

RHB Insurance Berhad (38000-U) FH198494

Level 12, West Wing, The Icon, No. 1, Jalan 1/68F, Jalan Tun Razak, 55000 Kuala Lumpur. Tel: 03-2180 3000 Fax : 03-9281 2729
( Service Tax Reg No : W10-1808-31042862 ) STAMP DUTY PAID

Foreign Worker Hospitalization & Surgical Scheme Certificate of Insurance

Intermediary : KL3011282 - KADAR HALUS SDN BHD - FORIEGN WORKER (INTERNAL)

Insured
Period Of Cover : 02-May-2020 to 25-Jul-2020 RM
Premium 146.71
Name : EURO SPACE INDUSTRIES (M) SDN BHD
MCO Fee RM 20.96
Address : WISMA EURO, LOT 21 INDUSTRIAL ESTATE 48000 Amount Payable excluding Tax RM 167.67
SELANGOR DARUL EHSAN GST (0.00%) RM 0.00
Service Tax (6%) RM 8.80
Nature Of Business : MANUFACTURING Stamp Duty RM 10.00
Business Reg. / NRIC / Passport No. : 105420-W
Payer : Employer Total Payable RM 186.47

Employment Location

No. Employment Code Employment Name Nature of Business Total Workman

#1 105420-W EURO SPACE INDUSTRIES (M) SDN BHD MANUFACTURING 6

Lives Insured
No. Name of Worker Emp. Loc. Passport No. Gender Work Permit Exp. Country
1 FORHAD HOSEN #1 BL0809542 M 25/07/2020 BANGLADESH
2 MOTALIB PAIKAR #1 BM0457157 M 25/07/2020 BANGLADESH
3 NAZMAL HOSSAIN #1 BM0603559 M 25/07/2020 BANGLADESH
4 NUR MOHAMMAD #1 BL0531705 M 25/07/2020 BANGLADESH
5 RAFIQUL ISLAM #1 BL0809523 M 25/07/2020 BANGLADESH
6 SHAKIL KHAN #1 BM0606558 M 25/07/2020 BANGLADESH

Total Workman Count: 6

RHB INSURANCE BERHAD

KONG SHU YIN

CHIEF EXECUTIVE OFFICER

In the event that any sales and services tax, value added tax or any similar tax and any other duties, taxes, levies or imposts (collectively referred to as “Applicable Tax”) whatsoever
are introduced by any authority and are payable under the laws of Malaysia in connection with any supply of goods and/or services made or deemed to be made under this Policy, the
Company will be entitled to charge the Policyholder for such amounts and the Policyholder agree to pay the Company the Applicable Tax allowed by the laws of Malaysia. Such
Applicable Tax payable shall be paid in addition to the applicable Premiums and other charges. All provisions in this Policy on payment of Premiums and default there of shall apply
equally to the Applicable Tax.

Sekiranya sebarang cukai jualan dan perkhidmatan, cukai nilai tambah atau sebarang cukai yang sama ( secara kolektif dirujuk sebagai “Cukai Berkaitan” dan sebarang duti, cukai,
levi atau apa sahaja impos yang lain diperkenalkan oleh mana mana pihak yang berkuasa dan perlu dibayar di bawah undang-undang Malaysia sehubungan dengan sebarang
pembekalan barang dan/atau perkhidmatan yang dilakukan atau dianggap telah dilakukan di bawah Polisi ini, pihak Syarikat berhak mengenakan bayaran kepada Pemegang Polisi
untuk amaun tersebut dan Pemegang Polisi bersetuju untuk membayar Cukai Berkaitan dan sebarang duti, cukai, levi, atau apa sahaja impos yang lain yang dibenarkan oleh undang
undang Malaysia kepada pihak Syarikat. Cukai, duti, levi atau impos yang perlu dibayar hendaklah dibayar sebagai tambahan kepada premium dan lain lain caj berkaitan. Semua
peruntukan di dalam Polisi ini berkenaan pembayaran premium dan keingkaran daripadanya hendaklah digunapakai secara sama untuk Cukai Berkaitan dan sebarang duti, cukai, levi
atau impos yang lain.

Printed On: 18/06/2019 02:52:58 PM

RHB Insurance Berhad (38000-U)
Level 12, West Wing, The Icon, No. 1, Jalan 1/68F, Jalan Tun Razak, 55000 Kuala Lumpur. Tel: 03-2180 3000 Fax : 03-9281 2729
( Service Tax Reg No : W10-1808-31042862 )

INVOICE

EURO SPACE INDUSTRIES (M) SDN BHD

WISMA EURO, LOT 21 INDUSTRIAL ESTATE 48000 SELANGOR DARUL EHSAN

TYPE OF POLICY : FOREIGN WORKER HOSPITALIZATION AND SURGICAL INSURANCE SCHEME

CERTIFICATE NO. : FH198494

TRANSACTION DATE : 12-Jun-2019

INVOICE NO : ETX201906616259
INVOICE DATE : 12-Jun-2019
PERIOD OF COVER : 02-May-2020 TO 25-Jul-2020
INSURED'S NAME : EURO SPACE INDUSTRIES (M) SDN BHD

INSURED'S ADDRESS : WISMA EURO, LOT 21 INDUSTRIAL ESTATE 48000 SELANGOR DARUL EHSAN

INTERMEDIARY ACCT. NO : KL3011282

INTERMEDIARY NAME : KADAR HALUS SDN BHD - FORIEGN WORKER (INTERNAL)

INTERMEDIARY ADDRESS : LEVEL 43A, MYEG TOWER, NO. 8, JALAN DAMANSARA, EMPIRE CITY, PJU

RINGGIT MALAYSIA RM
PREMIUM 146.71
LESS DISCOUNT 0.00
MCO FEE 20.96
TOTAL PAYABLE AMOUNT BEFORE TAX 167.67
ADD 6% SERVICE TAX 8.80
ADD STAMP DUTY 10.00
NET DUE 186.47

MCO Fee are collected and will be paid to Third Party Claims Administrator

THANK YOU.

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