21 June 2017

PUNUSAMY A/L
RENGGASAMY
NO 10 JLN KEMPAS INDAH
1/4
TMN KEMPAS INDAH
81300
JOHOR BHARU
JOHOR

Dear PUNUSAMY A/L RENGGASAMY,

Thank you for placing your trust in Liberty Insurance Berhad. Your continued support strengthens our commitment to constantly improve our
products and services to serve you better.

This letter confirm your puchase of motor insurance cover for your vehicle registration no : AFL3459 effective from 21/06/2017. It is important
that the policy, the Schedule and any amendments & notices are read together to avoid any misunderstandings.

Almost certainly your needs will change. If they do, please let us know - your Policy is designed for easy amendment or extension.

Our Promise of Services

We wish to provide you with a high standard of service and to meet any claims covered by this Policy honestly, fairly and promptly. Should you
have any reason to believe that we have not done so please contact, preferable in writing, your insurance adviser. If you do not have one, please
contact your Liberty Insurance at 1-800-888-990, who has wide authority and will be ready to help you with your problems.

IMPORTANT NOTICE TO POLICY HOLDER / NOTIS PENTING KEPADA PEMEGANG POLISI

Avenue to Resolve Your Insurance Complaint / Saluran Penyelesaian Aduan Insurans Anda

If you are not satisfied with Our response or decision, You may submit Your complaint to the avenues below. Kindly check with Our Company's
Complaints Unit on the proper avenue for dealing with Your Complaint.

Sekiranya anda tidak berpuas hati dengan maklumbalas atau keputusan Syarikat Kami, Anda boleh mengemukakan aduan Anda kepada saluran
saluran dibawah. Sila semak dengan Unit Aduan Syarikat Kami tentang saluran yang betul untuk mengemukakan aduan Anda.

1. Policyholders are hereby warned that under 1. Pemegang Polisi adalah diingatkan bahawa AVENUE TO RESOLVE YOUR
the Road Transport Act 1987, it shall be Akta Pengakutan Jalan 1987, adalah tidak INSURANCE COMPLAINT / Saluran
unlawful for any person to use or permit any sah bagi mana-mana orang lain Penyelesaian Aduan Insurans Anda
other person to use a motor vehicle without menggunakan sesuatu kenderaan motor
a valid Policy. tanpa Polisi/Sijil Insurans yang sah. Customer Complaints Unit /
Unit Aduan Pelanggan
2. Policyholders are further warned that on the 2. Pemegang Polisi juga diingatkan bahawa LIBERTY INSURANCE BERHAD
sale of a motor vehicle they must surrender selepas kenderaan dijual, mereka hendaklah Tingkat 10, Menara Liberty,
that Certificate of Insurance and the Policy menyerahkan Polisi dan Sijil Insurans 1008, Jalan Sultan Ismail,
to that Insurance Company. If the Certificate kepada Syarikat Insurans. Sekiranya Sijil 50250 Kuala Lumpur.
of Insurance has been lost or destroyed a Insuranshilang atau musnah, satu Akuan Tel No. : 03-2619 9000 Ext.9170/1-800-888-990
Statutory Declaration to that effect must be Berkanun hendaklah dibuat. Kegagalan Fax No. : 03-2693 2893
made. Failure to comply with this obligation untuk mematuhi kewajipan ini adalah satu
is an offence under the Road Transport Act. kesalahan dibawah Akta Pengakutan Jalan. Customer Services Bureau (CSB)
Jabatan Pengawalan Insurans,
3. The Policy will cease to be valid once the 3. Polisi akan tamat tempoh jika Kenderaan Bank Negara Malaysia,
Motor Vehicle has been sold to another telah dijual kepada orang lain melainkan Jalan Dato' Onn, 50480 Kuala Lumpur.
person unless the transfer of interest has Syarikat Insurans terbabit berpuashati dan Tel. No. : 03-2698 8044
been duly notified to and agreed by the bersetuju memindahkan kepentingan dalam Fax No. : 03-2694 5986
Insurance Company concerned. If the Polisi ini. Sekiranya Syarikat Insurans
Insurance Company agree to cover the new bersetuju untuk melindungi pemilik baru, Ombudsman for Financial Services
owner they will endorse the policy mereka akan membuat pengendorsan ke atas (664393P) /
accordingly and will issue a new Policy in polisi tersebut dan akan mengeluarkan satu Biro Pengantaraan Kewangan (664393P)
(Formerly known as Financial Mediation Bureau)
the new owners name. Sijil Insurans yang baru di atas nama Level 14, Main Block, Menara Takaful
pemilik baru. Malaysia, 4, Jalan Sultan Sulaiman
50000 Kuala Lumpur.
Tel. No.: 03-2272 2811
Fax No.: 03-2272 1577

We take the opportunity to thank you, for your support and confidence and look forward to continuing to service your needs both now and in the
future.

Yours sincerely,

LIBERTY INSURANCE BERHAD

David Tan
Chief Executive Officer
The Personal Data Protection Act 2010 came into force on 15 November 2013. Liberty Insurance Berhad is committed to protecting your
privacy. Please visit www.libertyinsurance.com.my for our complete and detailed privacy notice.
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LIBERTY INSURANCE BERHAD (16688-K) CUSTOMER SERVICE TOLL FREE : 1-800-888-990 | www.libertyinsurance.com.my
 THE SCHEDULE
JADUAL

STAMP DUTY PAID PRIVATE CAR INSURANCE POLICY

DUTI SETEM TELAH POLISI INSURANS KERETA PERSENDIRIAN
DIBAYAR

POLICY NUMBER KBMA-215398

NOMBOR POLISI
PUNUSAMY A/L RENGGASAMY ACCOUNT CODE
NO 10 JLN KEMPAS INDAH 1/4 KBAN125
KOD AKAUN TEGUH JAYA
TMN KEMPAS INDAH
81300 AGENCY
JOHOR BHARU
JOHOR BRANCH CODE KB - KOTA BHARU
KOD CAWANGAN
CLASS PRIVATE CAR
KELAS

NRIC : 591026-08-5207 Business Registration No :NOT APPLICABLE

No.Kad Pengenalan No.Pendaftaran Perniagaan
Business or Profession : OTHERS Cover Note No. :KBMA-215398
Perniagaan atau Pekerjaan No Nota Perlindungan
Period of Insurance : 21/06/2017 to 20/06/2018 Nationality :MALAYSIA
Tempoh Insurans Warganegara

Any subsequent period for which you shall pay and we shall agree to accept a renewal premium.
Sebarang tempoh selanjutnya di mana Anda hendaklah membayar, dan kami hendaklah bersetuju untuk menerima premium pembaharuan.
Vehicle Registration No. :AFL3459 Make & Type of Body : NISSAN / DATSUN -
No Pendaftaran Kenderaan Buatan & Jenis Badan NISSAN VANETTE
VPC22EFUP WINDOW
VAN
Regn. Card No. :- Engine No. : A15C075870
No Perakuan Pendaftaran No. Enjin
Kenderaan
C.C/Tonnage/HP :1488 CC Chassis No. : PN8VPC22JTCA43113
Keupayaan Enjin No. Chasis
Your Estimated Value :0.00 Seating Capacity : 8
Including Accessories Muatan Tempat Duduk Termasuk
Nilai Anggaran Anda Termasuk Pemandu
Aksesori
Year of Manufacture :2005 Type of Cover : THIRD PARTY
Tahun Diperbuat Perlindungan yang Diberi
Excess :0.00 Hire Purchase Owner :
Lebihan yang Dikenakan Syarikat Kewangan
Basic Premium: RM 135.00
Premium Asas
Loading :(+) (125.00%) RM 168.75
Penambahan
NCD :(-) (0.00%) RM 0.00
Diskaun Tanpa Tuntutan
Goods and Services Tax : (6.00%) RM 18.23
Cukai Barangan dan Perkhidmatan :
Stamp Duty : RM 10.00
Duti Setem :
Total : RM 332.00
Jumlah :
Act Premium : RM 273.38
Akta Premium :

LIBERTY INSURANCE BERHAD (16688-K) CUSTOMER SERVICE TOLL FREE : 1-800-888-990 | www.libertyinsurance.com.my
LEGISLATION
Road Transport Act.1987 (Malaysia) Motor Vehicle (Third Party Risks and Compensation) Act (CAP 189) Republic of Singapore Motor
Vehicles (Third Party Risks and Compensation) Rules 1960 (Republic of Singapore) Motor Vehicle Insurance(Third Party Risks) Act (CAP
90) Negara Brunei Darussalam(the reference to legislation under the heading "Avoidance of certain Terms and Right of Recovery" is
limited to Section 94,95,and 96 of the Road Transport Act 1987 (Malaysia) Section 7,8 and 9 of the Motor Vehicles (Third Party Risks and
Compensation) Act (Cap 189) Republic of Singapore and Section 7 of the Motor Vehicles Insurance (Third Party Risks) Act (Cap 90)
Negara Brunei Darussalam.

PERUNDANGAN
Akta Pengangkutan Jalan,1987 (Malaysia) Motor Vehicle(Third Party Risks and Compensation Act (Cap 189) Republic of Singapore The
Motor Vehicle (Third Party Risks and Compensation) Rules 1960 (Republic of Singapore) Motor Vehicles Insurance (Third Party Risks)
Act Cap 90 Negara Brunei Darussalam (rujukan kepada perundangan di bawah tajuk "Pengelakan Sesetengah Terma dan Hak Tuntut
Balik" adalah terhad kepada Seksyen 94,95 dan 96 Akta Pengangkutan Jalan 1987 (Malaysia) Section 7,8 and 9 of Motor Vehicles(Third
Party Risks and Compensation) Act (Cap 90) Republic of Singapore dan Section 7 of the Motor Vehicles Insurance (Third Party Risks) Act
(Cap 90) Negara Brunei Darussalam.

Authorised Driver :
Pemandu yang diberi kuasa

ENDORSEMENT / CLAUSE / WARRANTIES APPLICABLE TO THIS 3p, 100, 113

POLICY :
PENGENDORSAN / FASAL / WARANTI YANG DITERIMA PAKAI DI DALAM
POLISI INI:
Renewal of Policy No. :NOT APPLICABLE
Pembaharuan No. Polisi
Date of Signature of Proposal :
and Declaration
Tarikh Tandatangan Cadangan
dan Akaun
Entered by :teguhjaya
Operator
Issued at :KB Date: 21/06/2017
Dikeluarkan di Tarikh

PRINT DATE:
Tarikh dicetak

LIBERTY INSURANCE BERHAD (16688-K) CUSTOMER SERVICE TOLL FREE : 1-800-888-990 | www.libertyinsurance.com.my
CERTIFICATE OF INSURANCE
SIJIL INSURANS

POLICYHOLDER / PEMEGANG POLISI POLICY NUMBER / NOMBOR POLISI

KBMA-215398
PUNUSAMY A/L RENGGASAMY
NO 10 JLN KEMPAS INDAH 1/4 REGISTRATION NO. / No PENDAFTARAN
TMN KEMPAS INDAH
81300 AFL3459
JOHOR BHARU
JOHOR
PERIOD OF INSURANCE / TEMPOH INSURANS

From / Dari:21/06/2017
To / Hingga:20/06/2018

C.I CODE:M.X.1
Person or classes of person entitled to drive / Orang atau kelas orang yang layak memandu

a) The Policyholder.
b) Any other person who is driving on the Policyholder's order or with his permission.

Provided that the person is permitted in accordance with the licensing or other laws or regulations to drive the Motor Vehicle or has been so permitted and is not disqualified by
order of a Court of Law or by reason of any enactment or regulation in that behalf from driving the Motor Vehicle.
Dengan syarat orang tersebut dibenarkan memandu menurut undang-undang perlesenan atau undang-undang lain atau peraturan untuk memandu Kenderaan Bermotor
tersebut atau telah dibenarkan dan tidak dilucutkan kelayakan di atas perintah Mahkamah atau oleh sebab mana-mana enakmen atau peraturan daripada memandu Kenderaan
Bermotor tersebut.

LIMITATION AS TO USE*
HAD PENGUNAAN*

Use only for social, domestic and pleasure purposes and for the Policyholder's business.
The Policy does not cover :
(i) Use for hire or reward
(ii) Use for racing pace-making reliability trial or speed-testing
(iii) Use for the carriage of goods (other than samples) in connection with any trade or business

Limitation rendered inoperative by Section 95 of the Road Transport Act 1987 (Malaysia) or section 8 of the Motor Vehicle (Third Party Risks and Compensation) Act(189)
Repulic of Singapore or Section 7 of the Motor Insurance(Third Party Risks) Act(Cap90) Negara Brunei Darussalam are not to be included under this headingPengehadan
dijadikan tidak berkuatkuasa oleh Seksyen 95 Akta Pengangkutan Jalan 1987 (Malaysia) atau Section8 of the Motor Vehicle(Third Party Risks and Compensation)Act(Cap 189)
Republic of Singapore or Section 7 of the Motor Vehicle Insurance (Third Party Risks)Act(Cap 90)Negara Brunei Darussalam tidak termasuk dibawah tajuk ini.

LIBERTY INSURANCE BERHAD(16688-K)

David Tan
Chief Executive Officer

LIBERTY INSURANCE BERHAD (16688-K) CUSTOMER SERVICE TOLL FREE : 1-800-888-990 | www.libertyinsurance.com.my
CERTIFICATE OF INSURANCE
SIJIL INSURANS

a. This Certificate is not transferable.

Sijil ini tidak boleh dipindah

b. If the vehicle is sold to a new owner or for any reason the insurance is terminated or if the insurance is suspended during its currency ,
this Certificate must be returned to the Company for cancellation
Sijil ini hendaklah dikembalikan kepada Syarikat untuk pembatalan sekirany kenderaan telah dijual kepada pemilik baru atau insurans
ditamatkan atau digantung sebelum tamat tempoh insurans.

c. If the Certificate has been lost or destroyed, a Statutory Declaration to that effect must be mada.
Satu Akaun Berkanun hendaklah dibuat sekiranya Sijil ini hilang atau musnah.

d. Failure to comply with this obligation is an offence under Section 102 of the Road Transport Act 1987.
Kegagalan untuk mematuhi kewajipan ini adalah satu kesalahan di bawah Seksyen 102, Akta Pengangkutan Jalan 1987.

If you are involved in an accident causing injury to any property or other vehicle you must :-
Sekiranya anda terlibat di dalam kemalangan yang menyebabkan kecederaan kepada sesiapa atau kerosakan harta atau kenderaan lain, anda
mesti :-

a. Try to exchange insurance particulars with owners of other vehicle involved.

cuba untuk bertukar maklumat insurans dengan pemilik kenderaan yang terlibat.

b. Try to obtain the name and address of any witnesses to the accident.
cuba untuk mendapatkan nama dan alamat saksi saksi kepada kemalangan.

c. report to the police within 24 hours.

lapotkan kepada polis dalam tempoh 24 jam.

d. refer to the Company immediately.

rujuk kepada syarikat dengan segera.

e. refer to the Company immediately all communication received from the Police and send immediately to the Company all letter.receive
from third parties.
rujuk kepada syarikat dengan segera segala perhubungan yang diterima dari pihak Polis dan hantarkan kepada Syarikat semua surat
yang diterima dari pihak ketiga.

f. not pay any money to any party involved in the accident without the Company's written permission.
jangan membuat apa apa bayaran kepada sebarang pihak yang terlibat di dalam kemalangan tersebut tanpa kebenaran bertulis dari
pihak Syarikat.

g. it is an offence under the law of REPUBLIC OF SINGAPORE to enter the country without extending passanger liablity cover to your
motor insurance.
adalah menjadi satu kesalahan dibawah undang-undang REPUBLIK SINGAPURA jika memasuki Negara itu tanpa perlindungan
tambahan terhadap liability penumpang di dalam polisi anda.
# Attaching to and forming part of policy

POLICY CLAUSES APPLY FOR MOTOR (Individual Policies Only)

Code: FSA - Motor

CONSUMER INSURANCE CONTRACT

(Insurance wholly for purposes unrelated to your Trade, Business or Profession)

This Policy is issued in consideration of the payment of premium as specified in the Policy Schedule and pursuant to
the answers given in your Proposal Form (or when you applied for this insurance) and any other disclosures made by
you between the time of submission of your Proposal Form (or when you applied for this insurance) and the time this
contract is entered into. The answers and any other disclosures given by you shall form part of this contract of
insurance between you and us. However, in the event of any pre-contractual misrepresentation made in relation to
your answers or in any disclosures given by you, only the remedies in Schedule 9 of the Financial Services Act 2013
will apply.

This Policy reflects the terms and conditions of the contract of insurance as agreed between you and us.

DUTY OF DISCLOSURE

Where you have applied for this Insurance wholly for purposes unrelated to your trade, business or profession, you
had a duty to take reasonable care not to make a misrepresentation in answering the questions in the Proposal Form
(or when you applied for this insurance) i.e. you should have answered the questions fully and accurately. Failure to
have taken reasonable care in answering the questions may result in avoidance of your contract of insurance, refusal
or reduction of your claim(s), change of terms or termination of your contract of insurance in accordance with the
remedies in Schedule 9 of the Financial Services Act 2013. You were also required to disclose any other matter that
you knew to be relevant to our decision in accepting the risks and determining the rates and terms to be applied.

You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied
or renewed with us any of the information given in the Proposal Form (or when you applied for this insurance) is
inaccurate or has changed.

GOODS AND SERVICES TAX

The Goods and Services tax will be implemented by the Government of Malaysia with effect from 1 April 2015 at a
rate of 6% per centum. The Company reserves the right to collect from the Insured an amount equivalent to the GST
payable on the applicable premium for the policy period, or in the event that the policy commences before but expires
after 1 April 2015, to collect from the Insured an amount equivalent to the GST payable on the applicable premium
calculated from 1 April 2015 on a prorated basis.