Allianz General Insurance Company (Malaysia) Berhad (735426-V)

NO.300 & 301

JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

RTD CODE : 13
ORIGINAL COPY THE SCHEDULE STAMP DUTY PAID
JADUAL DUTI SETEM DIBAYAR

'
M.X.1 PRIVATE CAR EXCLUDING GOODS
Date of Issue/Time 13-02-2011
Tarikh Dikeluarkan/Waktu 12:37:36PM

PERIOD OF INSURANCE (a) From 13-02-2011 (both dates inclusive) E-Cover Note No. EAS-062370
Dari 13-02-2011 (termasuk kedua-dua tarikh)
TEMPOH INSURANS To 12-02-2012 No. Nota Perlindungan
Hingga 12-02-2012
(b) Any subsequent period for which the Account No. AS04864-00
Insured shall pay and the Company shall
agree to accept a renewal premium. No. Akaun
Sebarang tempoh selanjutnya di mana Anda hendaklah
membayar, dan Kami hendaklah bersetuju menerima Premium 745.20
premium pembaharuan.
Loading 0% 0.00
INSURED AZIZ BIN ISMAIL
PEMUNYA
NCD 0.00% 0.00
ADDRESS NO 17 TAMAN MAHSURI 1 JALAN KISAP MUKIM
ALAMAT
KUAH
07000 LANGKAWI GROSS PREM 745.20
SERVICE TAX 0% 0.00
OCCUPATION/TYPE OF BUSINESS OTHERS
PERNIAGAAN/PEKERJAAN STAMP DUTY 10.00
TOTAL DUE 755.20
HIRE PURCHASE OWNERS/EMPLOYER'S LOAN - AMOUNT
SEWA BELI/PINJAMAN MAJIKAN
PAYABLE(ROUNDED) 755.20
PARTICULARS OF VEHICLE EXCESS 0.00
BUTIR-BUTIR KENDERAAN LEBIHAN

Make and Type of Body Registration No./Trailer No.

Buatan dan Jenis Badan No. Pendaftaran/No. Treler
PERODUA KEMBARA 1.3EZ(A) KV1892C
Engine No. Engine C.C/Horse Power/Tonnage Act. 60.75
Akta
No. Enjin Cc Enjin/Kuasa Kuda/Tan
P013961 1,298.00 CC
Chassis No. Seating Capacity Year of Manufacture Sum Insured 21,000.00
Jumlah Diinsuranskan
No. Casis Muatan Tempat Duduk Tahun Dibuat
PM2J104G002074526 5 2005
NRIC No./Bus. Regn. No. Telephone No. Regn. Card No. Type of Cover
No. Kad Pengenalan/No. Pendaftaran Perniagaan No. Telefon No. Kad Pendaftaran Jenis Perlindungan
660418025365 - / - A2446806 Comprehensive
This Policyis subject to the following endorsements as printed in this Policy oradded thereon or attached thereto:-
Polisi ini adalah tertakluk kepada pengendorsan yang telah dicetak atauditambah atau dimasukkan kedalamnya.

ENDT. 1 - EXCESS ALL CLAIMS

ENDT. 2(f) - COMPULSORY EXCESS
ENDT. 30 - REPLACEMENT PARTS
ENDT. 100 - EXCLUSION OF LEGAL LIABILITY TO PASSENGERS - (Private Car Only)
ENDT. 106 - INSURER'S AUTHORISED WORKSHOP
ENDT. W.1 - WARRANTY NO 1

NAMED DRIVERS

1. THE POLICYHOLDER

LODGINGCOMPLAINTS & GRIEVANCES

IF YOU HAVE ANY COMPLAINTS OF UNFAIR MARKET PRACTICES BYTHE COMPANY, YOU MAY CALL OR WRITE TO :

1.COMPLAINTS UNIT 2.FINANCIAL MEDIATION BUREAU ("FMB") 3.PENGARAH

ALLIANZ GENERAL INSURANCE COMPANY LEVEL 25, DATARAN KEWANGAN DARUL TAKAFUL, JABATAN KOMUNIKASI KORPORAT
(MALAYSIA) BERHAD NO.4, JALAN SULTAN SULAIMAN, BANK NEGARA MALAYSIA
GROUND FLOOR, BLOCK 2A, 50000 KUALA LUMPUR. TINGKAT 14B,
PLAZA SENTRAL,JALAN STESEN SENTRAL 5, TEL : 03 - 2272 2811 PETI SURAT 10922,
KUALA LUMPUR SENTRAL, 50470 KUALA LUMPUR. FAX : 03 - 2274 5752 50929 KUALA LUMPUR.
TEL : 03 - 2264 0520 FAX : 03 - 2264 0602 EMAIL : enquiry@fmb.org.my TEL : 03 - 2698 8044 (General Line)
EMAIL : customer.service@allianz.com.my FAX : 03 - 2693 6919

GeographicalArea : Malaysia, Republic of Singapore and NegaraBruneiDarussalam . Issued By /Dikeluarkan oleh

KawasanGeografi : Malaysia, Republik of Singapura dan Negara BruneiDarussalam SYARIKAT PERUSAHAAN WIJAYA / CHAN CHING YEE
77,PERSIARAN MUTIARA PEKAN KUAH 07000 LANGKAWI KEDAH DARUL AMAN
Limitationsas to Use / Authorised Driver : As described in the Certificateof Insurance .
HadPenggunaan / Pemandu Yang Diberi kuasa : Seperti yang tercatat dalamSijil Insurans TEL : 04-9666425 FAX : -
Please ensure All accidents are reported to the Police within 24 hours.
Pastikan semua kemalangan hendaklah dilaporkan kepada pihak Polis didalam masa 24 jam.
Issued in lieu of and Cancelling/Replacing Cover Note/Policy No. -
DikeluarkanSebagai Pembatalan/Penggantian/No. Nota Perlindungan/ No. Polisi -

Date ofSignature of Proposal & Declaration

TarikhTandatangan Cadangan dan Akuan 13-02-2011

ImportanceNotice : Policy print out can be obtained from our branch offices locatednationwide or from your servicing agents.
KenyataanPenting : Cetakan polisi boleh diperolehi daripada pejabat cawangankami di seluruh negara ataupun daripada ejen Allianz Anda.
e-ASC 7*C01*-1002*23V0*1*9--5

Page 1 02-03-2011 16:04:01

 Allianz General Insurance Company (Malaysia) Berhad (735426-V)
NO.300 & 301
JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

RTD CODE : 13
OFFICE COPY THE SCHEDULE STAMP DUTY PAID
JADUAL DUTI SETEM DIBAYAR

'
M.X.1 PRIVATE CAR EXCLUDING GOODS
Date of Issue/Time 13-02-2011
Tarikh Dikeluarkan/Waktu 12:37:36PM

PERIOD OF INSURANCE (a) From 13-02-2011 (both dates inclusive) E-Cover Note No. EAS-062370
Dari 13-02-2011 (termasuk kedua-dua tarikh)
TEMPOH INSURANS To 12-02-2012 No. Nota Perlindungan
Hingga 12-02-2012
(b) Any subsequent period for which the Account No. AS04864-00
Insured shall pay and the Company shall
agree to accept a renewal premium. No. Akaun
Sebarang tempoh selanjutnya di mana Anda hendaklah
membayar, dan Kami hendaklah bersetuju menerima Premium 745.20
premium pembaharuan.
Loading 0% 0.00
INSURED AZIZ BIN ISMAIL
PEMUNYA
NCD 0.00% 0.00
ADDRESS NO 17 TAMAN MAHSURI 1 JALAN KISAP MUKIM
ALAMAT
KUAH
07000 LANGKAWI GROSS PREM 745.20
SERVICE TAX 0% 0.00
OCCUPATION/TYPE OF BUSINESS OTHERS
PERNIAGAAN/PEKERJAAN STAMP DUTY 10.00
TOTAL DUE 755.20
HIRE PURCHASE OWNERS/EMPLOYER'S LOAN - AMOUNT
SEWA BELI/PINJAMAN MAJIKAN
PAYABLE(ROUNDED) 755.20
PARTICULARS OF VEHICLE EXCESS 0.00
BUTIR-BUTIR KENDERAAN LEBIHAN

Make and Type of Body Registration No./Trailer No.

Buatan dan Jenis Badan No. Pendaftaran/No. Treler
PERODUA KEMBARA 1.3EZ(A) KV1892C
Engine No. Engine C.C/Horse Power/Tonnage Act. 60.75
Akta
No. Enjin Cc Enjin/Kuasa Kuda/Tan
P013961 1,298.00 CC
Chassis No. Seating Capacity Year of Manufacture Sum Insured 21,000.00
Jumlah Diinsuranskan
No. Casis Muatan Tempat Duduk Tahun Dibuat
PM2J104G002074526 5 2005
NRIC No./Bus. Regn. No. Telephone No. Regn. Card No. Type of Cover
No. Kad Pengenalan/No. Pendaftaran Perniagaan No. Telefon No. Kad Pendaftaran Jenis Perlindungan
660418025365 - / - A2446806 Comprehensive
This Policyis subject to the following endorsements as printed in this Policy oradded thereon or attached thereto:-
Polisi ini adalah tertakluk kepada pengendorsan yang telah dicetak atauditambah atau dimasukkan kedalamnya.

ENDT. 1 - EXCESS ALL CLAIMS

ENDT. 2(f) - COMPULSORY EXCESS
ENDT. 30 - REPLACEMENT PARTS
ENDT. 100 - EXCLUSION OF LEGAL LIABILITY TO PASSENGERS - (Private Car Only)
ENDT. 106 - INSURER'S AUTHORISED WORKSHOP
ENDT. W.1 - WARRANTY NO 1

NAMED DRIVERS

1. THE POLICYHOLDER

LODGINGCOMPLAINTS & GRIEVANCES

IF YOU HAVE ANY COMPLAINTS OF UNFAIR MARKET PRACTICES BYTHE COMPANY, YOU MAY CALL OR WRITE TO :

1.COMPLAINTS UNIT 2.FINANCIAL MEDIATION BUREAU ("FMB") 3.PENGARAH

ALLIANZ GENERAL INSURANCE COMPANY LEVEL 25, DATARAN KEWANGAN DARUL TAKAFUL, JABATAN KOMUNIKASI KORPORAT
(MALAYSIA) BERHAD NO.4, JALAN SULTAN SULAIMAN, BANK NEGARA MALAYSIA
GROUND FLOOR, BLOCK 2A, 50000 KUALA LUMPUR. TINGKAT 14B,
PLAZA SENTRAL,JALAN STESEN SENTRAL 5, TEL : 03 - 2272 2811 PETI SURAT 10922,
KUALA LUMPUR SENTRAL, 50470 KUALA LUMPUR. FAX : 03 - 2274 5752 50929 KUALA LUMPUR.
TEL : 03 - 2264 0520 FAX : 03 - 2264 0602 EMAIL : enquiry@fmb.org.my TEL : 03 - 2698 8044 (General Line)
EMAIL : customer.service@allianz.com.my FAX : 03 - 2693 6919

GeographicalArea : Malaysia, Republic of Singapore and NegaraBruneiDarussalam . Issued By /Dikeluarkan oleh

KawasanGeografi : Malaysia, Republik of Singapura dan Negara BruneiDarussalam SYARIKAT PERUSAHAAN WIJAYA / CHAN CHING YEE
77,PERSIARAN MUTIARA PEKAN KUAH 07000 LANGKAWI KEDAH DARUL AMAN
Limitationsas to Use / Authorised Driver : As described in the Certificateof Insurance .
HadPenggunaan / Pemandu Yang Diberi kuasa : Seperti yang tercatat dalamSijil Insurans TEL : 04-9666425 FAX : -
Please ensure All accidents are reported to the Police within 24 hours.
Pastikan semua kemalangan hendaklah dilaporkan kepada pihak Polis didalam masa 24 jam.
Issued in lieu of and Cancelling/Replacing Cover Note/Policy No. -
DikeluarkanSebagai Pembatalan/Penggantian/No. Nota Perlindungan/ No. Polisi -

Date ofSignature of Proposal & Declaration

TarikhTandatangan Cadangan dan Akuan 13-02-2011

ImportanceNotice : Policy print out can be obtained from our branch offices locatednationwide or from your servicing agents.
KenyataanPenting : Cetakan polisi boleh diperolehi daripada pejabat cawangankami di seluruh negara ataupun daripada ejen Allianz Anda.
e-ASC 7*C01*-1002*23V0*1*9--5

Page 2 02-03-2011 16:04:01

Allianz General Insurance Company (Malaysia) Berhad (735426-V)
NO.300 & 301
JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

RTD CODE : 13

CERTIFICATEOF INSURANCE
SIJILINSURANS
ORIGINAL COPY M.X.1
SALINANASAL

ROAD TRANSPORTACT, 1987 (MALAYSIA)

MOTORVEHICLES (THIRD PARTY RISKS) RULES 1959 (MALAYSIA)
MOTORVEHICLES (THIRD PARTY RISKS & COMPENSATION) ACT (CAP 189) REPUBLICOF SINGAPORE
MOTORVEHICLES (THIRD PARTY RISKS AND COMPENSATION) RULES 1960 (REPUBLIC OFSINGAPORE)
MOTORVEHICLES (THIRD PARTY RISKS) ACT (CAP 90) NEGARA BRUNEI DARUSSALAM

CERTIFICATE NO. EAS-062370 NCD 0.00%

No.Sijil DiskaunTanpa Tuntutan

1. Index Mark and Registration Number of Vehicle : KV1892C 1,298.00 CC PERODUA KEMBARA 1.3EZ(A)
TandaIndeks Dan Nombor Pendaftaran Kenderaan

2. Name of Policyholder : : AZIZ BIN ISMAIL

NamaPemegang Polisi

3. Effective date of the Commencement of : 13-02-2011

Insurancefor the purposes for the Regulations,
Ordinanceor Enactment
Tarikhefektif permulaan insuran untuk kegunaan Ordinan

4. Date of Expiry of the Insurance : 12-02-2012

TarikhLuput Insuran

5. Persons or Classes of Persons entitled to drive

Orangatau Kelas Pihak Yang Dibenarkan Memandu
(a) The Policyholder.
(b) Any other person who is driving on the Policyholder's order or with his permission.
(a) Pemegang Polisi.
(b) Sesiapa yang memandu atas arahan Pemegang Polisi atau dengan kebenarannya.
PROVIDED THAT THE PERSON IS PERMITTED IN ACCORDANCE WITH THELICENSING OR OTHER LAWS OR REGULATIONS TO DRIVE
THE MOTOR VEHICLE ORHAS BEEN SO
PERMITTEDAND IS NOT DISQUALIFIED BY ORDER OF A COURT OF LAW OR BY REASON OF ANYENACTMENT OF REGULATIONS IN
THAT BEHALF FROM DRIVING THE MOTORVEHICLE.
6. Limitations as to use* HadPenggunaan
Use only for social, domestic and pleasure purposes and for the Policyholder's business.
The policy does not cover use for hire or reward, racing, pace-making reliability trial, speed testing, the carriage of goods other than samples in
connection with any trade or business or use for any purpose in connection with the motor trade.
Digunakan hanya untuk tujuan sosial, domestik dan persiaran dan untuk perniagaan Pemegang Polisi.
Polisi ini tidak melindungi kegunaan untuk sewaan atau ganjaran, perlumbaan, mengkadar kelajuan, ujian kebolehpercayaan, ujian kelajuan,
membawa barangan selain daripada sampel yang berkaitan dengan apa-apa pekerjaan atau perniagaan.

ThisCertificate is not transferable to a new owner of the Vehicle.

If for any reason the Insurance is terminated during itscurrency this Certificate must be returned to the Company or if thisCertificate has been lost or destroyed a Statutory Declaration to
thateffect must be made. Failure to comply with this obligation is anoffence under the compulsory Insurance Legislation.

This Certificate must be returned if the insurance issuspended during its currency.

IMPORTANT

If you are involved in an accident causing injury to anyperson or damage to any property or other vehicle you must :
(a) Try toobtain names and address of any witness to the accident.
(b) Reportto the Company immediately.
(c) Referto the Company immediately all communications received from the PoliceAuthorities.
(d) Sentto the Company immediately all letters from Third Parties unanswered.
(e) Notpay money to any Party involved in the accident without the Company'swritten permission.

* Limitations renderedinoperative by Section 95 of the Road Transport Act, 1987 (Malaysia)or Section 8 of the Motor Vehicles (Third Party Risks andCompensation) Act (Cap 189)
Republic of Singapore or Section 7 of theMotor Vehicles Insurance (Third Party Risks) Act (Cap 90) NegaraBrunei Darussalam are not included under this heading.
Had yang tidak beroperasi oleh Seksyen 95 Akta Pengangkutan Jalan1987 (Malaysia) atau Seksyen 8 Akta Kenderaan Bermotor (Gantirugi danRisiko Pihak Ketiga) (Cap 189) Republik Singapura
atau Seksyen 7 AktaSingapura atau Seksyen 7 Akta Insurans Kenderaan Bermotor (RisikoPihak Ketiga) (Cap 90) Negara Brunei Darussalam adalah tidak termasukdi bawah tajuk ini.

I/Wecertify that the Policy to which the Certificate is issued inaccordance with the provisions of Part IV of the Road Transport Act,1987 (Malaysia), Motor Vehicles (Third Party Risks and
Compensation)Act (Cap 189) Republic of Singapore and the Motor VehiclesInsurance(Third Party Risks) Act (Cap 90) Negara Brunei Darussalam.
Saya/Kamibersetuju bahawa Polisi di mana Sijil ini dikeluarkan tertakluk dibawah proviso Bahagian IV Akta Pengangkutan Jalan 1987. (Malaysia)Akta Kenderaan Bermotor (Risiko Pihak Ketiga &
Gantirugi) (Cap189) Republik Singapura dan Akta Kenderaan Bermotor (Risiko PihakKetiga) (Cap 90) Negara Brunei Darussalam.

Agent Code : AS04864-00

Kod Ejen

e-ASC 7*C01*-1002*23V0*1*9--5

Page 3 02-03-2011 16:04:01

Allianz General Insurance Company (Malaysia) Berhad (735426-V)
NO.300 & 301
JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

Cover Note No. : EAS-062370

CREDIT CARD PAYMENT
PLEASE COMPLETE THIS FORM IN FULL

Name of Cardholder : ____________________________________________________________

Please charge to my credit :( ) Visa ( ) MasterCard for RM : ___________________

card account
Card No : |__|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__|

Card Expiry Date : |__|__| - |__|__|

Issuing Bank : ___________________________________________________________

Contact Number : |__|__|__| - |__|__|__|__|__|__|__|__|

For Proposer Use only:

Payment for :

MOTOR ( ) PERSONAL ACCIDENT ( )

( )
CASH PLAN ( ) SPECIAL OCCUPATION PA
( )
GOLF MASTER ( ) HOUSEOWNER/HOUSEHOLDER
MILLION DOLLAR PA ( ) Others (please specify) : ___________ ( )

For Agent Use only:

Agent Account Number : AS04864-00 Checked by:
Motor (MT) : RM_________________________ Signature : ______________________________
Non Motor (NM) : RM_________________________ Name : ______________________________
Premium Warranty (PW) : RM_________________________ Designation : ______________________________
Date : ______________________________

"I/We hereby authorize the debit of my account as above and declare that I/we have read and agree to be bound by the Terms and Conditions
herein pertaining to my credit card payment for the policy."

___________________________
Cardholder's Signature

"TERMS AND CONDITIONS FOR CREDIT CARD PAYMENTS

1. In these terms and conditions, the following expressions shall bear the following meanings:-"Card" shall refer to the VISA Credit Card or MASTERCARD Credit Card issued by RHB Bank or any other
bank, financial institution or legalentity authorised by VISA INTERNATIONAL and MASTERCARD INTERNATIONAL respectively;"Cardholder" shall refer to the lawful and authorised user of the Card
whose name is embossed thereon and whose signature appears on the Card;"Card Issuer" shall refer to the bank, financial institution or legal entity which is the issuer of the Card;"Insured" shall refer to
the person(s) or entities that are named in the Policy;"Policy" shall refer to the insurance policy that is described above; 2. The Insured declares and undertakes to Allianz General Insurance Company
(Malaysia) Berhad ("Allianz") that:-(a) the information supplied by the Insured is true and correct;(b) the Card nominated for payment of the Policy ("Payment") is in the name of the Insured. Where the
Card so nominated is in the name of a third party, the Insured declares and undertakes that the Cardholder has authorised the Insured to use the Card for the Payment;(c) the Insured is the lawful and
authorised holder of the Card or where the Card belongs to a third party, that the Cardholder is the lawful and authorised holder of the Card;(d) the Card is valid and has not expired; and;(e) the Card has
not been suspended or terminated.3. The Insured hereby authorises Allianz to:-(a) verify the information supplied with the Card Issuer or any third party as may be necessary;(b) forward the Insured's
details to the Card Issuer and other relevant parties for and in connection with the Payment;(c) retain and return the Card to the Card Issuer in the event that the same has been declared invalid,
cancelled, reported lost or deemed unacceptable by the Card Issuer;(d) share its database on the Insured with such relevant parties for Allianz's marketing programmes and/or towards the detection and
prevention of crime. 4. The Insured acknowledges and agrees that the acceptance of the Payment is subject to prior authorisation from the Card Issuer through the supplied terminals and against an
unexpired and valid Card.5. Allianz, its employees and/or authorised agents shall not be liable to the Insured:-(a) if the Card is not honoured by the Card Issuer; (b) if authorisation to the Cardholder for
the Payment is denied, refused or suspended by any party for any reason whatosever;(c) if Allianz, its employees and/or authorised agents is/are unable or delay(s) in completing the Card transaction for
the Payment as a result of power failure, failure of any computer or telecommunications system or any other circumstances beyond the reasonable control of Allianz, its employees and/or authorised
agents; and(d) for any loss or damages whatsoever suffered by the Insured arising from using the Card for Payment."

e-ASC 7*C01*-1002*23V0*1*9--5

Page 4 02-03-2011 16:04:01

Allianz General Insurance Company (Malaysia) Berhad (735426-V)
NO.300 & 301
JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

PLEASE PRINT IN BLOCK LETTERS. BEFORE COMPLETING, READ THE WARRANTIES HEREIN (Tick [/] where applicable)
SILA ISI DENGAN MENGGUNAKAN HURUF BESAR DAN BACA SEMUA WARANTI YANG TERKANDUNG DISINI (Tandakan [/] Yang Berkenaan)

A. DETAILS OF PROPOSER / BUTIR-BUTIR PENCADANG

Name / Nama: AZIZ BIN ISMAIL
Address / Alamat: NO 17 TAMAN MAHSURI 1
JALAN KISAP
MUKIM KUAH
Postcode / Poskod: 07000 If vehicle is not garaged at the above address, provide postcode of where it is garaged Postcode / Poskod:
Jika kenderaan tidak disimpan di alamat seperti diatas, nyatakan poskod ia disimpan.
LANGKAWI
Date Of Birth / 18-04-1966 Old IC No. / Passport No. / No. New IC No. / No. Kad 660418025365
Tarikh Lahir: Kad Pengenalan Lama / No. Pengenalan Baru
Pasport

Gender / Body Male Year Licence Obtained / Tahun Driving License Number / No.
Corporate / Jantina / Lesen Diperolehi Siri Lesen Memandu
Badan Korporat:

Marital Status / Married Occupation / Type of Business / OTHERS Business Registration No. /
Taraf Perkahwinan Pekerjaan / Jenis Perniagaan No. Pendaftaran Perniagaan

Phone Number / No. Telefon -, -, - E-Mail Address / Alamat E-Mail

* [House / Rumah] [Office / Pejabat] [Handset / Bimbit]

B. SCOPE OF COVER / PERLINDUNGAN

Period of Insurance Required / Tempoh Insurans Dipohon 00:01 AM , 13-02-2011, 12-02-2012
Note: The period of Insurance of this policy when issued will not commenced earlier than the date and time of receipt of premium
Perhation: Tempoh perlindungan Insurans polisi ini akan hanya berkuatkuasa dari tarikh premium dibayar atau diterima

Type of Insurance Required / Jenis Perlindungan Dipohon New Business - Transfer of Ownership
Purpose for which vehicle is used / Tujuan Kenderaan digunakan PRIVATE CAR - PRIVATE USE
Geographical Location: Others
Address where the vehicle will be usually garaged overnight. /
Alamat kenderaan biasanya ditempatkan pada waktu malam

Is the vehicle to be insured under: / Adakah kenderaan yang -

diinsuranskan dibawah:
Co. or HP Name / Sykt. Atau Nama Penyewa

C. DESCRIPTION OF VEHICLE / BUTIR-BUTIR KENDERAAN

Make / Model PERODUA KEMBARA 1.3EZ(A)
Buatan / Modal

Year of Manufacture / Tahun di Age of Vehicle / Usia Body Type / Jenis Badan Saloon Convertible
2005
Perbuat Kenderaan

Engine No. / No. Enjin Van 4x4

P013961

Chassis No. / No. Casis Coupe Others

PM2J104G002074526
Cubic Capacity / 1,298.00 CC Registration No. / KV1892C Log Book No. (Attached Copy) / No. Buku A2446806
Kuasa Enjin No. Pendaftaran Pendaftaran (lampirkan salinan)

Sum Insured inclusive of: (Air cond) / Nilai Insurans RM 21,000.00 Seating Capacity / Muatan Tempat 5
termasuk (Hawa dingin) Duduk

Road Tax Expiry Date Anti Theft Device Installed / Pemasangan Alat With Mechanical Device - Other
Mencegah Kecurian

Airbags Installed / None ABS Braking System Installed / None

Permasangan Beg Angin Pemasangan Sistem Brek ABS

Has this vehicle been modified for purpose of speed and / or acceleration beyond the manufacturer's specification? If Yes, please specify types of modifications. Adakah kenderaan ini telah di ubahsuai
untuk tujuan kelajuan dan / atau pemecutan melebihi spesifikasi perkilangan? Jika Ya, nyatakan jenis modifikasi.

Purchase Price / Harga Beli - Date of Purchase of Vehicle / Tarikh Belian -

D. DRIVERS / PEMANDU
Name / Nama New NRIC No / No Kad Sex / Driving Experience (Years) / Jantina / Occupation / Pekerjaan
Pengenalan Baru Pengalaman Memandu (Tahun)
THE POLICYHOLDER

e-ASC 7*C01*-1002*23V0*1*9--5

Page 5 02-03-2011 16:04:01

Allianz General Insurance Company (Malaysia) Berhad (735426-V)
NO.300 & 301
JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

E. CLAIMS HISTORY / SEJARAH TUNTUTAN

Please give below the last 3 years' accident experience of the insured in respect of the vehicle being insured and any other Motor Vehicle owned or driven by you or by any person who will drive this
vehicle. / Sila beri keterangan tentang semua kemalangan yang melibatkan anda dan kenderaan lain milik anda yang anda pandu atau dipandu oleh pemandu lain bagi tempoh 3 tahun yang lalu.

Date of Accident Vehicle No. Name of Insured Nature of Loss/Injury Amount Claimed from Insurer
Tarikh No. Kenderaan Nama Syarikat Insurans Jenis Kerugian/Kecederaan Jumlah tuntutan dari Syarikat Insurans
Kemalangan

F. EXTENDED COVERS / PERLINDUNGAN TAMBAHAN

-

G. CLAIM FREE YEARS / TAHUN BEBAS TUNTUTAN

[Note: This Discount is now applicable as a rating factor in computing your premium] / [Nota: Diskaun ini digunapakai sebagai faktor pengiraan premium anda]

1. Have you been insured in the past 12 months. If Yes, give name of insurer and branch? / Pernahkah anda diinsuranskan bagi tempoh 12 bulan yang lalu? Jika ya, sila beri nama Syarikat
Insurans dan cawangannya.

Yes / Ya No / Tidak
______________________________________________________________________________________________________________________________________

(Attached either one of the following documents with the number of CFY entitlement / NCD percentage stated on it. / Lampirkan mana-mana dokumen dibawah ini yang tertera jumlah kelayakan TBT /
peratus DTT di atasnya)

- Original Policy Schedule / Salinan Asal Polisi

- Renewal Notice issued by Insurer / Notis Pembaharuan yang dikeluarkan oleh pihak insurans
- Endorsement / Endosmen
- Certificate of Insurance / Sijil Insurans
- Or CFY confirmation Letter / atau surat pengesahan TBT

2. Policy No. / No. Polisi ___________________________________________________ 3. Reg. No. of vehicle insured / No. Kenderaan yang diinsuranskan __________

4. Period of Insurance / Tempoh Insurans:From / Dari ______________________________________ To / Hingga _______________________________

5. Claim Free Years entitlement allowed currently / Kelayakan Tahun Bebas Tuntutan yang diperolehi kini ___________ Claim Free Year(s) / Tahun Bebas Tuntutan ___

6. Has any insurer ever declined your proposal/imposed special term/cancelled or refused to renew your policy? If Yes, please give particulars. / Pernahkah mana-mana pihak insurans menolak
permohonan anda / mengenakan terma khas / membatalkan atau enggan membaharui polisi anda? Jika Ya, nyatakan penjelasan

Yes / Ya No / Tidak
______________________________________________________________________________________________________________________________________

DECLARATION / PENGAKUAN
I/We hereby declare that
1) All the information given in the proposal form and any attachment to it is true and correct
2) All information known to me/us which may be relevant to the decision to insure and the terms of the insurance has been given
3) I/We further declare and agree
a) to be bound by terms, conditions, exceptions and operational warranties of the Policy which have been brought to my/our specific attention.
b) that the statement and declarations in this proposal form shall be the basis of the contract of insurance with Allianz General Insurance Company (Malaysia) Berhad
and are deemed to be incorporated in the contract.
Dengan ini saya/kami mengakui dan mengesahkan sepanang pengetahuan kami bahawa
1) Semua kenyataan yang terkandung didalam Borang Cadangan ini adalah benar dan betul
2) Semua keterangan yang diketahui oleh saya/kami yang mana akan mempengaruhi keputusan bagi menginsuranskan kenderaan dan syarat insurans telah dinyatakan.
3) Saya/Kami seterusnya mengakui dan bersetuji
a) tertakluk kepada syarat-syarat pengecualian dan kepada waranti polisi yang mana telah dikemukakan kepada pengetahuan saya/kami secara terperinci
b) bahawa semua kenyataan dan pengakuan yang terkandung didalam Borang Cadangan ini akan menjadi asas kepada perjanjian kontrak insurans dengan Allianz
General Insurance Company (Malaysia) Berhad yang juga diperbadankan dalam perjanjian ini.
Important Notice To Prospective Policy Owners:
Policy owners are advised to read the policy carefully and understand the contents therein. You are encouraged to seek clarification from the insurer if necessary.
Notis Penting Kepada Bakal Pemegang Polisi:
Pemegang Polisi adalah dinasihatkan supaya membaca polisi dengan berhati-hati dan faham isi kandungannya. Anda adalah digalakkan agar mendapatkan penjelasan
daripada Pihak Penanggung Insurans jika perlu.

Dated / Bertarikh________________________ month of / bulan ____________________ Year /Tahun_____________________

PROPOSER / PENCADANG

Signature
Tandatangan ______________________________________________
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Allianz General Insurance Company (Malaysia) Berhad (735426-V)
NO.300 & 301
JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

ROAD WARRIOR PROPOSAL FORM

THE ROAD WARRIOR INSURANCE
P.A. Benefits PAYMENT PER UNIT / PER PERSON
RW DPPA

A. Accidental Death/Permanent Disablement/Loss of both hands or RM10,000 RM10,000

feet or sight of both eyes/Loss of one eye and one hand or one
foot/Total paralysis (from neck down) or permanent quadraplegia
(loss or permanent total loss of use of four limbs)
B. Loss of one foot or one hand or sight of one eye RM5,000 RM5,000
C. Insanity or loss of four fingers and thumb in one hand/Loss of RM5,000 -
hearing of both ears or speech
D. Loss of all toes RM2,000 -
E. Double Indemnity (for death or permanent disablement if accident RM20,000 RM10,000
occurs during a nationwide public holiday)
F. Medical Expenses Up to RM1,000 RM500.00
G. Bereavement RM500 RM500.00
H. Cosmetic Surgery Up to RM1,000 -
I. Hospital Income (up to 60 days) RM30 per day -
Note:- RW * Except for Double Indemnity benefit, the aggregate
of all losses payable in respect of any one accident
shall not exceed RM10,000 per unit per person under the above section.
* Children between the ages 15 days to 15 years are entitled to 50% of the benefits hereinabove.

Car Breakdown Assistance (RW Only)

i. 24 hours emergency towing and minor road side repairs
ii. Car replacement assistance
iii. Arrangement for hotel accommodation
iv. Referral to car service centre
v. Referral to doctors and hospitals
vi. Legal assistance
vii. Emergency message transmission
Table of Premium (RW)
Please choose coverage [Tick /] 1 unit 2 units 3 units 4 units 5 units
Seating Capacity (incl driver)
4 seats RM50 [ ] RM95 [ ] RM135 [ ] RM175 [ ] RM215 [ ]
5 seats RM60 [ ] RM114 [ ] RM162 [ ] RM210 [ ] RM258 [ ]
6 seats RM70 [ ] RM133 [ ] RM189 [ ] RM245 [ ] RM300 [ ]
Each Additional Seat RM8 [ ] RM15 [ ] RM21 [ ] RM27[ ] RM33 [ ]
Please add RM10 for stamp duty.

In the event of emergency, please give name and telephone number of family/person to be contacted.

Name: ____________________________________________________

Telephone No/Handphone No: ________________________________

DECLARATION

I hereby declare that I did not suffer from any deformity or any fits. I agree to accept the company's policy subject to the terms and conditions contained
therein or endorsed thereon.

......................................................
|__|__|__|__|__|__| Signature of Proposer
DATE
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Allianz General Insurance Company (Malaysia) Berhad (735426-V)
NO.300 & 301
JALAN LUMPUR
05100 ALOR STAR 05100 ALOR STAR
Tel: 04-7334655 Fax: 04-7337868 Email:info@allianz.com.my

DECLARATION / LETTER OF UNDERTAKING

AKUAN/SURAT AKUJANJI

To : Allianz General Insurance Company (Malaysia) Berhad (735426-V) Name & Address of Insured
Kepada Nama & Alamat Insured

AZIZ BIN ISMAIL

NO 17 TAMAN MAHSURI 1
JALAN KISAP
MUKIM KUAH

Dear Sir,
Tuan,
NCD ENTITLEMENT :
KELAYAKAN NCD
VEHICLE NO :
NO KENDERAAN
I/C NO (OLD) : (NEW)
NO K/P (LAMA) (BARU)

I am/ We are currently holding a valid *Comprehensive / Third Party policy with .................................... (current Insurer).
Saya/Kami sedang memegang polisi *Komprehensif / Pihak Ketiga yang sah dengan .................................... (penanggung insurans semasa).

I/We intend to transfer or claim my .............................. NCD entitlement to a vehicle No. ............................................to be insured with
Saya/Kami ingin memindah atau menuntut kelayakan NCD saya ..........................terhadap kenderaan No..............................................yang akan diinsuranskan dengan

You or purchase a policy from Your Company. (See Note No. 1)

Anda atau membeli sebuah polisi dengan Syarikat Anda.(Lihat Nota No. 1)

I/ We hereby confirm that :

Dengan ini saya/kami mengesahkan bahawa:

a) the NCD stated on the document *(Original Policy Schedule / Renewal Notice issued by Insurance company / Endorsement / Certificate
of insurance ) is TRUE and correct.
NCD yang tercatat pada dokumen * (Jadual Asal Polisi/ Notis Pembaharuan yang dikeluarkan oleh syarikat insurans/ Endorsemen/ Sijil Insurans) adalah BENAR dan betul.

b) to be the best of my / our knowledge no claim or Action has been lodged / pending or is likely to be taken against me / us under the
policy.
Sepanjang pengetahuan Saya/Kami tiada tuntutan atau Tindakan telah dikemukakan / belum selesai atau berkemungkinan di ambil terhadap Saya/Kami di bawah polisi ini.

c) there is no breach of any policy conditions which affetcs my NCD entitlement.

Tiada pelanggaran terhadap apa-apa syarat polisi yang menjejaskan kelayakan NCD saya.

d) I/We have not and shall not use this entitlement of NCD for any other vehicle / policy.
Saya/Kami tidak dan tidak akan mengguna kelayakan NCD ini untuk kenderaan/polisi lain.

e) if the NCD is incorrect. I / We undertake to pay the difference of premium within 14 working days, failing which I / We agree the policy
may be cancelled by the company.
Jika NCD itu salah Saya/Kami mengakujanji untuk membayar perbezaan premium dalam tempoh 14 hari bekerja, dan kegagalan berbuat demikian Saya/Kami bersetuju bahawa
polisi ini boleh dibatalkan oleh syarikat.

Enclosed is a copy of * (Original Schedule / Renewal Notice Issued by Insurance company / Endorsement / Certificate of Insurance ) as
evidence of my entitlement.
Bersama-sama ini dikepilkan satu salinan * (Jadual Asal/Notis Pembaharuan yang dikeluarkan oleh syarikat insurans/Endorsemen/Sijil Insurans) sebagai bukti kelayakan saya.

............................................
Insured Signature
Tandatangan Insured

Note :
Nota:

1. If the transfer of NCD is between two different vehicles, please enclose the relevant Cancellation / recovery NCD Endorsement for verification.
Jika pemindahan NCD adalah di antara dua kenderaan berbeza, sila kepilkan Pembatalan/pemungutan Endorsemen NCD untuk penentusahan.

2. NCD from Overseas

NCD dari Luar negeri
Condition : Duly Signed Declaration Letter and submit together with the Original NCD letter stating the number of claims free years.
Syarat:Surat Akuan yang Ditandatangani dan dihantar bersama surat NCD asal dengan menyatakan bilangan tahun bebas tuntutan.

(Photostate copy is not accepted)

(Salinan fotostat tidak diterima)
* Delete whichever is not appropriate.
* Potong mana yang tidak berkenaan
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