TOKIO MARINE INSURANS (MALAYSIA) BERHAD

(Co. No. 149520-U)

29th - 31st Floor, Menara Dion, 27, Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia.
Tel: 03-2026 9808 Fax: 03-2026 9708
Tell us your experience
with Tokio Marine
MOTOR INSURANCE SCHEDULE / JADUAL INSURANS MOTOR
CLASS / POLICY : PRIVATE CAR-PRIVATE USE(PRIVATE CAR FOR PRIVATE USE)
KELAS / POLISI
POLICY NO. : V2113915 (VT151989)
NO. POLISI
DATE: 02-05-2019
THE INSURED & ADDRESS : MOHD SALIMIN BIN SAHLUDIN TARIKH
PEMILIK & ALAMAT
ACCOUNT NO.: WF-00124540
2620 JALAN BSS 3/1C BANDAR SEREMBAN SELATAN NO. AKAUN
71450 SEREMBAN NEGERI SEMBILAN
AGENT NAME: LASER MOTOR SDN.
PERIOD OF INSURANCE : a. FROM 02/05/2019(11:39 AM) TO 01/05/2020 NAMA EJEN BHD.
TEMPOH PERLINDUNGAN DARI HINGGA
(BOTH DATES INCLUSIVE) ACT: 40.58
(TERMASUK KEDUA-DUA TARIKH) AKTA
b. ANY SUBSEQUENT PERIOD FOR WHICH THE INSURED SHALL PAY (RM)
AND THE COMPANY SHALL AGREE TO ACCEPT A RENEWAL
PREMIUM PREMIUM: 1,287.98
MANA-MANA TEMPOH SELANJUTNYA YANG MANA PIHAK PREMIUM
DIINSURANSKAN HENDAKLAH MEMBAYAR DAN SYARIKAT NCD 55.00% 708.39
HENDAKLAH BERSETUJU MENERIMA SATU PREMIUM DISKAUN TANPA
PEMBAHARUAN TUNTUTAN:
CONTACT NO: : 0192776171 (WEF:02/05/2019):
/ TALIAN UNTUK DIHUBUNGI EXT. PREMIUM: 240.00
I/C NO. (NEW) / BARU : 680518-06-5047 / PREMIUM TAMBAHAN:
NO. KP (OLD) /LAMA SERVICE TAX 6.00%: 49.18
PASSPORT NO CUKAI PERKHIDMATAN
NATIONALITY : Malaysia 6.00%:
/ KEWARGANEGARAAN STAMP DUTY: 10.00
BUSINESS / PROFESSION : ENGINEER CONSULTANT DUTI SETEM
PERNIAGAAN / PEKERJAAN TOTAL: 878.77
BUSINESS REGN NO. : JUMLAH
NO. PENDAFTARAN SYARIKAT

VEHICLE MAKE MODEL & TYPE H.P/CUBIC CAPACITY/ YEAR OF SEATING CAPACITY INSURED'S ESTIMATE OF VALUE
REGISTRATION NO. OF BODY TONNAGE OR WATT MANUFACTURE INCLUDING DRIVER INCLUDING ACCESSORIES & SPARE PARTS
NO. PENDAFTARAN MODEL BUATAN DAN H.P/KEUPAYAAN TAHUN KAPASITI TEMPAT (RM)
KENDERAAN JENIS BADAN ENJIN/ TAN ATAU DIPERBUAT DUDUK TERMASUK NILAI ANGGARAN ANDA TERMASUK
WATT PEMANDU AKSESORI & ALAT GANTIAN (RM)
NCJ3564 TOYOTA INNOVA 2.0G 1998 C 2010 8 43,000.00
ENGINE/MOTOR : 1TR6891257 CHASSIS NO. : PN111NV4008621267
NO.NO.ENJIN/MOTOR NO.CASIS
NAMED DRIVERSPEMANDU YANG : THE INSURED,HASNAH BINTI HAMID
DINAMAKAN
HIRE PURCHASE OWNERS : MALAYAN BANKING BERHAD TYPE OF COVER : COMPREHENSIVE
PEMILIK SEWA BELI JENIS PERLINDUNGAN
REGISTRATION CARD NO : NIL EXCESS : 0.00
NO. KAD PENDAFTARAN LEBIHAN

SUBJECT OTHERWISE TO TERMS, EXCEPTIONS AND CONDITIONS OF THE POLICY AND THE ENDORSEMENT / WARRANTY /MEMORANDUM AS NUMBERED
BELOW:
SELAINNYA TERTAKLUK KEPADA TERMA, PENGECUALIAN DAN SYARAT-SYARAT POLISI INI DAN PENGENDORSAN / WARANTI / MEMORANDUM SEPERTI
TERSEBUT DIBAWAH:

W.1 , 89 , 113 , 15 (RM) (RM)

Code Description Value Premium
89 BREAKAGE OF GLASS IN W/SCREEN 1600.00 240.00
Geographical Area: Malaysia, Republic of Singapore and Negara Brunei Darussalam.
Kawasan Geografi: Malaysia, Republik Singapura dan Negara Brunei Darussalam.
Limitation as to use / Authorised Driver: As described in the Certificate of Insurance.
Had Penggunaan/Pemandu yang diberi kuasa: Seperti yang tercatat dalam Sijil Insuran.
RENEWAL OF POLICY NO. : V0077713
PEMBAHARUAN POLISI NO.
DATE OF PROPOSAL & DECLARATION : 02-05-2019
TARIKH CADANGAN & PENGISTIHARAN
ISSUED AND SIGNED AT : WF
DIKELUARKAN DAN DITANDATANGANI
ISSUED BY : 0012454001
DIKELUARKAN OLEH __________________________
Chief Executive Officer
Ketua Pegawai Eksekutif
TOKIO MARINE INSURANS (MALAYSIA) BERHAD

Important Notice/Kenyataan Penting:

1.No policy wordings are attached. You may view the wordings at www.tokiomarine.com or visit our branch or your servicing agents for the print out. For Insuranceinfo Fact
Sheet, it is available at Tokio Marine website www.tokiomarine.com.
Tiada butir-butir lengkap polisi disertakan. Anda boleh melayari www.tokiomarine.com atau pergi ke pejabat cawangan atau ejen anda untuk mendapatkan cetakan polisi.
Untuk Lembaran Fakta Info Insuran, ia boleh didapati di laman web Tokio Marine www.tokiomarine.com.
2.This policy may be subjected to Service Tax (ST) of 6% effective 1 September 2018. Tokio Marine Insurans (Malaysia) Berhad reserves the right to collect the amount
of Service Tax due in relation to policies with coverage period beginning or spanning the effective date.
Polisi ini mungkin tertakluk kepada 6% Cukai Perkhidmatan (CP) berkuat kuasa 1 September 2018.
Tokio Marine Insurans (Malaysia) Berhad berhak membuat kutipan Cukai Perkhidmatan ke atas premium bagi tempoh polisi yang bermula pada atau melepasi tarikh
kuatkuasa Cukai Perkhidmatan.
02-05-2019 11:39:31
 TOKIO MARINE INSURANS (MALAYSIA) BERHAD
(Co. No. 149520-U)

ROAD TRANSPORT ACT 1987 (MALAYSIA) MOTOR VEHICLE (THIRD PARTY RISKS)
RULES 1959 MALAYSIA MOTOR VEHICLES (THIRD PARTY RISKS & COMPENSATION)
ACT (CAP 189) REPUBLIC OF SINGAPORE MOTOR VEHICLE (THIRD PARTY RISKS & COMPENSATION)
RULES 1960 (REPUBLIC OF SINGAPORE) MOTOR VEHICLES INSURANCE THIRD PARTY
RISKS ACT (CAP 90) NEGARA BRUNEI DARUSSALAM
MX1
CERTIFICATE OF INSURANCE
SIJIL INSURANS
CERTIFICATE NO. / POLICY NO.: V2113915 (VT151989)
NO SIJIL/NO POLISI
1. Index Mark and Registration Number of NCJ3564
Vehicle:
Tanda Indeks dan No. Pendaftaran Kenderaan
2. Name of Policyholder: MOHD SALIMIN BIN SAHLUDIN
Nama Pemegang Polisi
3. Effective date of the Commencement of 02/05/2019
Insurance:
Tarikh Kuatkuasa Tempoh Insurans
4. Date of Expiry of the Insurance: 01/05/2020
Tarikh Tamat Tempoh Insurans
5. Person or Classes of Persons 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 driving 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 atau peraturan untuk
memandu Kenderaan Bermotor tersebut atau telah dibenarkan dan tidak dilucutkan kelayakannya atas perintah Mahkamah atau atas
sebab mana-mana enakmen atau peraturan daripada memandu Kenderaan Bermotor.

6. Limitations as to use:
Had-had Penggunaan
Use only for social domestic and pleasure purposes and for the Policyholder's business.
The Policy does not cover:
(1) Use for hire or reward.
(2) Use for racing pace-making reliability trial or speed-testing.
(3) Use for the carriage of goods other than samples in connection with any trade or business.
(4) Use for any purpose in connection with the Motor Trade.

Limitations rendered inoperative by Section 95 of the Road Transport Act 1987 (Malaysia) or Section 8 of the Motor Vehicles (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 are not included under this heading.
Pengehadan dijadikan tidak berkuat kuasa oleh Seksyen 95 Akta Pengangkutan Jalan 1987 (Malaysia) atau Section 8 of the Motor
Vehicles (Third Party Risks and Compensation) Act (Cap 189) Republic of Singapore or Section 7 of the Motor Vehicle Insurance (Third
Party Risks) Act (Cap90) Negara Brunei Darussalam tidak termasuk di bawah tajuk ini.

I / We certify that this covering note is issued in accordance with the provisions of Part IV of the Road Transport Act 1987 (Malaysia),
Motor Vehicles (Third Party Risks & Compensation) Act (Cap 189) Republic of Singapore and the Motor Vehicle Insurance (Third Party
Risks) Act (Cap 90) Negara Brunei Darussalam.
Saya/Kami dengan ini mengesahkan bahawa Nota Perlindungan ini yang diperuntukan mengikut Bahagian IV Akta Pengangkutan Jalan
1987 (Malaysia), Motor Vehicles (Third Party Risks & Compensation) Act (Cap 189) Republic of Singapore and the Motor Vehicle
Insurance (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam.
ISSUING DATE: 02-05-2019
TARIKH
DIKELUARKAN

AGENCY NO.: WF 00124540

NO. AGENCY

ISSUED BY:
DIKELUARKAN LASER MOTOR SDN. BHD.
OLEH
__________________________
Chief Executive Officer
Ketua Pegawai Eksekutif
TOKIO MARINE INSURANS (MALAYSIA) BERHAD
02-05-2019 11:39:31
 TOKIO MARINE INSURANS (MALAYSIA) BERHAD
(Co. No. 149520-U)
Service Tax Number: W10-1808-31013285
29th-31st Floor, Menara Dion,
27, Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia

INVOICE
INVOIS
POLICY NO. : V2113915 (VT151989) INVOICE NO. : F1937756
NO POLISI NO INVOIS
ACCOUNT NO. : 00124540 DATE : 02/05/2019
NO AKAUN TARIKH
THE INSURED : MOHD SALIMIN BIN SAHLUDIN
PIHAK DIINSURANKAN
ADDRESS : 2620 JALAN BSS 3/1C
ALAMAT BANDAR SEREMBAN SELATAN

71450
SEREMBAN
NEGERI SEMBILAN

CLASS OF INSURANCE : CVP-PRIVATE CAR FOR PRIVATE USE

KELAS INSURANS
PERIOD OF INSURANCE : 02/05/2019 TO 01/05/2020
TEMPOH INSURANS
PARTICULARS TOTAL
BUTIR-BUTIR JUMLAH

PREMIUM : RM 819.59
PREMIUM

REBATE -0.00% : RM 0.00

REBAT

SUBTOTAL : RM 819.59
JUMLAH KECIL

SERVICE TAX +6.00% : RM 49.18

CUKAI PERKHIDMATAN

SUBTOTAL AFTER SERVICE TAX : RM 868.77

JUMLAH KECIL SELEPAS SERVICE
TAX

STAMP DUTY : RM 10.00

DUTI SETEM

NET TOTAL : RM 878.77

JUMLAH BERSIH
Note:
This policy is subject to Service Tax(ST), unless specifically exempted under the Service Tax Act 2018.
Polisi ini tertakluk kepada Cukai Perkhidmatan melainkan jika dikecualikan oleh Akta Cukai Perkhidmatan 2018.
TOKIO MARINE INSURANS (MALAYSIA) BERHAD

--------------------------------------
AUTHORISED SIGNATORY
(TANDATANGAN PIHAK BERKUASA)
 TOKIO MARINE INSURANS (MALAYSIA) BERHAD RTD CODE:91
(Co. No: 149520-U)

29th-31st Floor, Menara Dion,

27, Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia

PRIVATE MOTOR CAR INSURANCE PROPOSAL FORM

BORANG CADANGAN INSURANS KERETA PERSENDIRIAN
IMPORTANT NOTICES
NOTIS PENTING
Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for purposes
unrelated to your trade, business or profession, you have a duty to take reasonable care not to make a misrepresentation in answering the
questions in the Proposal Form (or when you apply for this insurance). You must answer the questions fully and accurately. / Menurut
Perenggan 5 daripada Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon Insurans ini sepenuhnya untuk tujuan yang tidak
berkaitan perdagangan, perniagaan atau profesion anda, anda mempunyai kewajipan untuk mengambil langkah yang munasabah untuk
tidak salah nyata dalam menjawab soalan-soalan di dalam Borang Cadangan (atau semasa memohon insurans ini). Anda dikehendaki
menjawab soalan-soalan dalam Borang Cadangan ini dengan lengkap dan tepat.
Failure to take 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. / Kegagalan untuk mengambil langkah yang munasabah
dalam menjawab soalan-soalan, mungkin mengakibatkan pembatalan kontrak insurans anda, keengganan atau pengurangan gantirugi,
perubahan terma atau penamatan kontrak insurans anda.
The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. /
Perlindungan tidak diberikan sekiranya pembayaran premium tidak dijelaskan mengikut peraturan yang dikeluarkan di bawah seksyen ini.
Sesiapa yang gagal mematuhinya akan didapati bersalah dan dikenakan denda tidak lebih RM500,000. Pembayaran premium yang
dibuat dengan cek, wang pos dan draf bank hendaklah dipalang di atas "Akaun Penerima Sahaja" dan di atas nama syarikat
penginsurans.
Kewajipan pendedahan di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami.
In addition to answering the questions in the Proposal Form (or when you apply for this insurance), you are required to disclose any other
matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. / Sebagai
tambahan kepada soalan-soalan di dalam Borang Cadangan (atau semasa memohon insurans ini), anda dikehendaki untuk
mendedahkan apa-apa perkara lain yang anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar
dan terma yang dikenakan.
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. / Anda juga
mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda
ditandatangani, diubah atau diperbaharui dengan kami (atau semasa permohonan insurans ini), apa-apa maklumat yang dinyatakan
dalam Borang Cadangan tidak tepat atau sudah berubah.
Average Clause/Fasal Purata
It is hereby understood and agreed that if the motor vehicle shall at the time of happening of any loss or damage be insured for a sum less
than its market value then, the insured shall be considered as being his own insurer for the difference and shall bear the rateable
proportion of the loss accordingly. Provided that this clause shall not apply unless the market value at the time of the loss exceeds the
insured value by 10%.
Adalah difahamkan dan dipersetujui jika kenderaan bermotor semasa berlaku sebarang kejadian atau kerosakan diinsuranskan di bawah
harga pasaran, pemilik dikehendaki membayar sendiri semua p erbezaan dan akan menanggung kerugian mengikut kadar kerosakan.
Fasal ini tidak perlu diguna pakai melainkan harga pasaran semasa berlaku kerugian melebihi 10% jumlah insuran.
Passenger Liability Cover / Perlindungan Liabiliti Penumpang
It is an offence under the laws of the Republic of Singapore to enter the country without extending passenger liability cover to your motor
insurance.
Di bawah Undang-undang Republik Singapura, adalah menjadi satu kesalahan jika memasuki negara tersebut tanpa perlindungan liabiliti
ke atas penumpang anda.
(EVERY QUESTION MUST BE ANSWERED. YOU MUST FULLY AND CLEARLY GIVE THE INFORMATION ASKED)
SETIAP SOALAN HARUSLAH DIJAWAB. ANDA PERLU MENGISI DAN MEMBERI INFORMASI YANG DIPERLUKAN DENGAN JELAS
Proposer's name MOHD SALIMIN BIN SAHLUDIN New NRIC 680518-06-5047
Nama Pencadang No. KP Baru
Address 2620 JALAN BSS 3/1C Telephone No. 0192776171
Alamat BANDAR SEREMBAN SELATAN No. Tel.
71450 SEREMBAN
NEGERI SEMBILAN
Old NRIC/Business Regn. No. / Date of Birth 18-05-1968
Passport No. Tarikh Lahir
No. KP Lama/No. Pendaftaran
Perniagaan/No.Passport
Corporate Type
Jenis Korporat
Marital Status Single/ Married/ Divorced/ Gender Male/ Female Driving Experience 0 Yrs
Taraf Perkahwinan Widow Jantina Lelaki/Perempuan Pengalaman Memandu Thn
Bujang/Berkahwin/Bercerai/Lain-lain
Occupation ENGINEER Regn. Card No. NIL Driving License No.
Pekerjaan CONSULTANT No. Kad Pendaftaran No. Lesen Memandu
Vehicle Regn. No. NCJ3564 Trailer No. Period of Cover From 02/05/2019 To 01/05/2020
No. Pendaftaran No. Pendaftaran Tempoh Dari Hingga
Kenderaan Kenderaan Perlindungan
Engine No. 1TR6891257 Chassis No. PN111NV4008621267
No. Injin No. Casis
Make & Model TOYOTA INNOVA 2.0G Seating Capacity 8 cc/tonnage/passenger 1998 C
Buatan & Model MPV Tempat Duduk cc/ton/penumpang
Year of Make 2010 Hire Purchase MALAYAN BANKING BERHAD
Tahun Diperbuat Pinjaman
Type of Cover Comprehensive / Third Party / Third Party Fire & Theft / Act Only
Tahun Diperbuat Komprehensif/Pihak Ketiga Kebakaran & Kecurian/Polisi Akta
Use of Vehicle PRIVATE CAR FOR PRIVATE Sum Insured 43000.00
Trailer Sum Insured
Kegunaan Kenderaan USE Jumlah Perlindungan Jumlah
Perlindungan Treler
Named Drivers/New NRIC THE INSURED / 680518-06-5047,HASNAH BINTI HAMID / 670828-05-5136
Nama Pemandu/No KP Baru
Additional Benefits BREAKAGE OF GLASS IN W/SCREEN
Perlindungan Tambahan(Subject to additional NAMED DRIVERS
premium)
(Tertakluk kepada tambahan premium)

Class of Vehicle PRIVATE CAR-PRIVATE USE

Kelas Kenderaan
Please indicate any Anti-Theft Devices installed on your vehicle
Sila nyatakan adakah kenderaan anda dilengkapi dengan Peralatan Anti Kecurian
With Mechanical Device (steering lock, gear lock,etc) Without Mechanical Device (stering lock, gear lock,
Dengan Peralatan Mekanikal (Pengunci stering, pengunci gear, dsbgnya) etc)
Tanpa Peralatan Mekanikal (pengunci stering,
pengunci gear, dsbgnya)
Alarm, Immobilizer & Global Positioning System (GPS) or Satellite Alarm with Immobilizer
Detection Alat Penggera dengan Immobilizer
Alat Penggera, Immobilizer & GPS atau Pengesanan Satelit
Factory Fitted Alarm No Alarm
Alat Penggera Dipasang dari Kilang Tanpa Alat Penggera
Others (Please Specify)
Lain-lain (Sila nyatakan)__________
Please indicate the Safety Features on your vehicle
Sila nyatakan Ciri-ciri Keselamatan kenderaan anda
ABS & Airbags (more than 2) ABS & Airbags (2) ABS & Airbags (1) Airbags (More than 2)
ABS dan Beg Udara (lebih dari 2) ABS dan Beg Udara (2) ABS dan Beg Udara (1) Beg Udara (2)
Driver & Passenger Airbags(2) Driver's Side Airbags (1) ABS (No Airbags) None
Bag udara Pemandu & Beg udara Sisi Pemandu (1) ABS (Tanpa Beg Udara) Tiada
Penumpang (2)
Please indicate where the vehicle is usually parked when not in use
Sila nyatakan dimana kenderaan anda kerap diletakkan jika tidak digunakan
Locked Garage Unlocked Garage Locked Compound Unlocked Compound
Garaj Berkunci Garaj Tidak Berkunci Kawasan Halaman Kawasan Halaman Tidak
Berkunci Berkunci
Open Public Car Park Secure Public Car Park Public Road
Tempat Letak Tempat Letak Kereta Awam Jalan Awam
Kereta Awam Terbuka Dengan Fungsi Keselamatan
Please declare any modifications to the vehicle Yes / No
Sila nyatakan sebarang pengubahsuaian ke atas Ya / Tidak
kenderaan
If yes, please give full details / Sekiranya ya, sila nyatakan butiran lengkap

Do you suffer from any physical/mental illness Yes / No

Adakah anda mengalami kecacatan fizikal/mental Ya / Tidak
If yes, please give full details / Sekiranya ya, sila nyatakan butiran lengkap

Have you been involved in any motor accident or made any claims during the past (3) years? Yes / No
Pernahkah anda terlibat dalam kemalangan atau membuat tuntutan sepanjang tiga tahun yang lepas Ya / Tidak
If yes, please give full details of previous insurer(s) and the accident(s). Sekiranya ya, sila nyatakan butiran lengkap pengisurans terdahulu
dan kemalangan.

Kindly list out other current/proposed insurance covers taken or to be taken with our Company
Sila nyatakan lain-lain perlindungan insurans yang telah diambil atau akan diambil dengan syarikat kami

Payment Instruction / Arahan Pembayaran

I enclose a cheque/bank draft/money order
Saya sertakan cek/bank draf/kiriman wang pos (No. ..........................................................................................)
If paying by credit card / Jika membayar dengan kad kredit
Paying by credit card MasterCard Visa
Bayar dengan kad kredit
Name of Cardholder
Nama Pemegang Kad _______________________________________
Card Number Expiry Date
Nombor Kad Tarikh Luput

Amount payable to
Jumlah RM............................................. bayar kepada TOKIO MARINE INSURANS (MALAYSIA) BERHAD
 (inclusive of RM10 stamp duty and 6.00% Service Tax where applicable/
termasuk duti setem RM10 dan Cukai Perkhidmatan sebanyak 6.00% jika perlu)

________________________________ _________________________
Signature of Cardholder Date / Tarikh
Tandatangan Pemegang Kad

Acknowledgement & Declaration / Perakuan & Pengisytiharan

Personal Data Protection Act 2010 (PDPA) Notice / Notis Akta Perlindungan Data Peribadi 2010
I/We acknowledge and consent that the personal data, including any sensitive personal data, collected herein be used, processed and
disclosed for the purpose of this proposal to reinsurers; individuals or organizations associated with Tokio Marine Group, or any selected
third party (within or outside Malaysia). I/We acknowledge that I/we am/are obligated to provide the above personal data failing which
my/our proposal could not be processed and that I/we am/are entitled to obtain access to, request for correction of or limit the processing
of my/our personal data; and
Saya/Kami mengakui dan bersetuju bahawa data peribadi, termasuk apa-apa data peribadi yang sensitif, yang dikumpulkan di sini
digunakan, diproses dan dizahirkan untuk tujuan cadangan ini kepada penanggung insurans semula; individu atau organisasi yang
berkaitan dengan Kumpulan Tokio Marine, atau sebarang pihak ketiga (di dalam atau di luar Malaysia). Saya/Kami mengakui bahawa
saya/kami perlu memberikan data peribadi di atas, dan jika gagal berbuat demikian, cadangan saya/kami tidak dapat diproses dan
saya/kami berhak untuk mendapatkan akses kepada, meminta pembetulan atau mengehadkan pemprosesan data peribadi saya/kami;
dan
I/We further agree that you may disclose and share my/our information with individuals or organizations associated with Tokio
Marine Group, strategic partners and other third parties (within or outside Malaysia) as the Company deems fit for the purpose of
cross-selling, promoting and marketing financial products and services offered by you and the other entities.
Saya/Kami juga bersetuju bahawa anda boleh mendedahkan dan berkongsi maklumat saya/kami dengan individu atau organisasi
yang berkaitan dengan Kumpulan Tokio Marine, rakan strategik dan pihak ketiga lain (di dalam atau di luar Malaysia) yang
difikirkan patut untuk tujuan jualan silang, promosi dan pemasaran produk dan perkhidmatan kewangan yang ditawarkan anda dan
entiti-entiti lain.
Protection of your privacy is very important to us. Please visit our website at www.tokiomarine.com to view our Privacy Statement.
Perlindungan privasi anda adalah sangat penting bagi kami. Sila layari laman web kami di www.tokiomarine.com untuk melihat Penyata
Privasi kami.
Declaration/Pengisytiharan
I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal
Form and I/we hereby declare that I/we have fully and accurately answered the questions above.
Saya/Kami faham bahawa menjadi tanggungjawab saya/kami untuk mengambil langkah yang munasabah untuk tidak salah nyata semasa
menjawab soalan-soalan dalam Borang Cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab dengan
sepenuhnya dan dengan tepat soalan di atas.

_________________________
Signature of Proposer Date / Tarikh
Tandatangan Pemohon Insurans

02-05-2019 11:39:31
Verification of Identity / Pengesahan Pengenalan
In compliance with Section 16(2) of the Anti-Money Laundering Act 2001
I hereby certify that the Proposer's original NRIC/Business Registration Certificate was verified and authenticated by me at the point of
sales.

Selaras dengan pematuhan Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram 2001
Saya dengan ini mengesahkan bahawa Kad Pengenalan/Sijil Pendaftaran Perniagaan asal pemohon telah disahkan ketulenannya
semasa urusniaga dijalankan.

Third party verification / Pengesahan pihak ketiga

Name / Nama Signature / Tandatangan

__________________________________ __________________________________

NRIC no. / No. Kad Pengenalan Date / Tarikh

__________________________________

"Third party" means insurance agents, insurance brokers or staff of insurance companies
"Pihak ketiga" bermaksud ejen insurans, broker insurans atau kakitangan syarikat insurans.

Note : To maintain a copy of NRIC for applicants for individual insurance policies where the premium is more than RM50,000.
Nota : Sesalinan KP perlu disimpan bagi pemohon yang mengambil polisi insuran individu dimana premiumnya melebihi RM50,000.
Tokio Marine Insurans (Malaysia) Berhad is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia
Tokio Marine Insurans (Malaysia) Berhad dilesenkan di bawah Akta Perkhidmatan Kewangan 2013 dan dikawalselia oleh Bank Negara
Malaysia
 LETTER OF UNDERTAKING
SURAT DISKAUN TANPA TUNTUTAN
I am currently holding a valid *Comprehensive/Third Party motor policy with ................... (current Insurer).
Pada masa ini, Saya memegang polisi motor *Komprehensif/Pihak ketiga yang sah dengan ................... (Penanggung Insurans
sekarang).
I intend to transfer or claim my ...55.00%... NCD entitlement to a Vehicle No. ....NCJ3564.... to be insured with You or purchase a policy
from Your company.
Saya ingin memindahkan atau menuntut ...55.00%... Kelayakan Diskaun Tanpa Tuntutan saya ke kenderaan bernombor ....NCJ3564....
untuk diinsuranskan dengan Anda atau membeli polisi daripada syarikat Anda

I hereby confirm that :-

Saya dengan ini mengesahkan bahawa :-
(a) To the best of my knowledge I have not been involved in an accident in which a claim or Court Action has been lodged/pending or
is likely to be taken against me under the policy.
Dalam pengetahuan saya, saya tidak pernah terlibat dalam sebarang kemalangan di mana ada tuntutan atau Tindakan Mahkamah
telah dibuat/belum selesai atau kemungkinan akan diambil terhadap saya di bawah polisi ini.
(b) There is no breach of any policy condition(s) which affects my NCD entitlement.
Tiada perlanggaran pada mana-mana syarat polisi yang boleh menjejaskan kelayakan Diskaun Tanpa Tuntutan saya.
(c) I have not and shall not use this entitlement of NCD for any other vehicle/policy.
Saya belum dan tidak akan menggunakan kelayakan Diskaun Tanpa Tuntutan ini untuk mana-mana kenderaan/polisi yang lain.
(d) if the NCD is incorrect, I undertake to pay the difference of premium within 14 working days, failing which I agree the policy may be
cancelled by the company.
sekiranya Diskaun Tanpa Tuntutan ini tidak betul, Saya memberi akujanji untuk membayar balik perbezaan premium dalam masa
14 hari bekerja, sekiranya gagal berbuat demikian, Saya bersetuju polisi saya dibatalkan oleh Syarikat

Applicable if NCD is given before confirmation with the ISM NCD Database
Diguna pakai sekiranya Diskaun Tanpa Tuntutan telah diberikan sebelum mendapat pengesahan dari Pengkalan Data NCD ISM

1. Enclosed is a copy of * (Original Policy Schedule/Renewal Notice issued by insurance company/Endorsement /Certificate of
Insurance) as evidence of my entitlement.
Dilampirkan sesalinan *(Jadual Polisi Asal/Notis Pembaharuan yang dikeluarkan oleh syarikat insurans/Pengendorsan/Sijil
Insurans) sebagai bukti kelayakan saya.
2. If the transfer of NCD is between two different vehicles, please enclose the relevant Cancellation/Recovery NCD Endorsement for
verification.
Jika pemindahan Diskaun Tanpa Tuntutan adalah antara dua kenderaan berasingan, sila lampirkan Pengendorsan
Pembatalan/Pengembalian Balik Diskaun Tanpa Tuntutan berkenaan untuk pengesahan.

_______________________
Insured Signature
Tandatangan Pihak Diinsuranskan
Note:
Nota:

NCD from Overseas

Diskaun Tanpa Tuntutan daripada Luar Negara

Duly signed Letter of Undertaking and the original NCD confirmation letter stating the number of claim free years must be submitted.
Surat Akujanji yanag ditandatangani sewajarnya dan surat pengesahan asal Diskaun Tanpa Tuntutan yang menyatakan bilangan tahun
bebas tuntutan mestilah disertakan.

* delete whichever is not appropriate

* potongan yang mana tidak berkenaan.
02-05-2019 11:39:31