COVER NOTE

STAMP DUTY PAID

Policyholder Cover Note No. : V6502400

Account No. : V0029350
RAZILAWATI BINTI AB RAZAK Agent Name : ZAHIRI AGENCY
NO 13 JLN PUTERA INDAH 10/3A
BNDR PUTERA INDAH Product Type : Motor Cycle Private
BATU PAHAT Period of Insurance from 04/03/2021 To 03/03/2022 (both Dates
83010 JOHOR Inclusive). Any subsequent period for which the Insured shall pay and
the Company shall agree to accept a renewal premium.

NRIC No : 820325-06-5544 Business Reg No : Vehicle Estimated Value RM 0.00

Business/Occupation : 1st Class : Others Other ID No : Gross Premium RM 82.60
Vehicle Information Add: Loading 50.00% RM 41.30
JPJ Document No : Less: No Claim Discount RM 24.78
20.00%
Vehicle Reg No : JTC3989 Log Book No : NIL
______
Make : MOTORCYCLE
RM 99.12
Model : MOTORCYCLE BENELLI TNT600
Add : Service Tax 6.00 % RM 5.95
Engine No : BJ465MS-A78014517 Cover Type : Third Party
Stamp Duty RM 10.00
Chassis No : ZBNP25022HB800848 Vehicle Type : Motor Cycle Private
Year of : 2018 License Type : Normal Cycle
Manufacture TOTAL AMOUNT DUE RM 115.07
Cubic Capacity : 600 Use For : Private Use
Seating Capacity : 2 Rider Type : Single Rider
Excess Damage Claims RM 0.00
Financial Interest : NIL

IMPORTANT NOTICE - APPLICABLE TO ALL CONSUMER PRODUCTS

(Insurance wholly for purposes unrelated to your trade, business or profession)
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 Application 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 Application Form (or when You applied for this Insurance) is inaccurate or has changed.

Issue Date : 04-03-2021/02:24 PM For and on behalf of

Issue At : D1 Etiqa General Insurance Berhad
Issue By : v0029350a

Visit www.etiqa.com.my or our nearest branch to obtain the full policy wordings.
Help preserve the country's natural resources.
 Invoice No: EIBG2021UWFL00081772
Date: 04/03/2021

INVOICE

ETIQA GENERAL INSURANCE BERHAD (9557T)

LEVEL 19 TOWER C
DATARAN MAYBANK
NO 1 JALAN MAAROF
59000 KUALA LUMPUR
(SST Reg No: W10-1808-31009769)

To Account Number: V0029350

RAZILAWATI BINTI AB RAZAK
NO 13 JLN PUTERA INDAH 10/3A
BNDR PUTERA INDAH
BATU PAHAT
83010 JOHOR

Description Total (RM)

Type of Policy: Motor Cycle Private
Policy Number: V6502400
Period of Cover: 04/03/2021 to 03/03/2022

Premium 99.12
Total (Excluding SST) 99.12
SST payable @ 6.00% 5.95
Stamp Duty 10.00

Total Amount Payable 115.07

This is a computer generated document. Therefore, no signature is required