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
NAMED DRIVERS
1. THE POLICYHOLDER
IF YOU HAVE ANY COMPLAINTS OF UNFAIR MARKET PRACTICES BYTHE COMPANY, YOU MAY CALL OR WRITE TO :
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
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
NAMED DRIVERS
1. THE POLICYHOLDER
IF YOU HAVE ANY COMPLAINTS OF UNFAIR MARKET PRACTICES BYTHE COMPANY, YOU MAY CALL OR WRITE TO :
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
RTD CODE : 13
CERTIFICATEOF INSURANCE
SIJILINSURANS
ORIGINAL COPY M.X.1
SALINANASAL
1. Index Mark and Registration Number of Vehicle : KV1892C 1,298.00 CC PERODUA KEMBARA 1.3EZ(A)
TandaIndeks Dan Nombor Pendaftaran Kenderaan
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.
e-ASC 7*C01*-1002*23V0*1*9--5
"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
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
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)
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
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
Year of Manufacture / Tahun di Age of Vehicle / Usia Body Type / Jenis Badan Saloon Convertible
2005
Perbuat Kenderaan
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
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.
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
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
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)
2. Policy No. / No. Polisi ___________________________________________________ 3. Reg. No. of vehicle insured / No. Kenderaan yang diinsuranskan __________
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.
Signature
Tandatangan ______________________________________________
e-ASC 7*C01*-1002*23V0*1*9--5
In the event of emergency, please give name and telephone number of family/person to be contacted.
Name: ____________________________________________________
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
e-ASC 7*C01*-1002*23V0*1*9--5
To : Allianz General Insurance Company (Malaysia) Berhad (735426-V) Name & Address of Insured
Kepada Nama & Alamat Insured
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
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.
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.