ORIGINAL COPY MOTORCYCLE STAMP DUTY PAID

JADUAL MOTOSIKAL DUTI SETEM DIBAYAR

Insured Name : HARON BIN NEKMAT Policy No..............................: V7814500

Nama Pemegang Polisi No. Polisi
Address : PG 56 KAMPONG PARIT GANTONG Account No...........................: AWM07248
Alamat PARIT SULONG BATU PAHAT JOHOR No. Akaun
83500 PARIT SULONG
JOHOR NRIC No...............................: 640616016541
No. Kad Pengenalan
Bus. Regn. No.......................: NA
No. Pendaftaran Perniagaan
Business / Profession: Office Workers Regn. Card No.......................: VEK6075
Perniagaan / Pekerjaan No Kad Pendaftaran
Period Of : a) From 26-07-2021 @ 3:09PM To 25-07-2022 @ 12 midnight
Insurance Dari Hingga
Tempoh Insurans
b) Any subsequent period for which the Insured shall pay and the Company shall agreed to accept a renewal premium
Sebarang tempoh selanjutnya di mana Anda hendaklah membayar dan Kami hendaklah bersetuju menerima premium
pembaharuan.
Type of Cover : Comprehensive Engine No : KF29E8056029
Jenis Perlindungan No. Enjin
Vehicle Registration : VEK6075 Chassis No : PMKKF37A0KB004054
No No Casis
No Pendaftaran
Year of Manufacture : 2019 Cubic Capacity : 149 CC
Tahun Dibuat Keupayaan Enjin
Make & Type of : Honda Vario Seating Capacity : 2
Body Bilangan Tempat
Buatan & Jenis Badan Duduk
Insured's Estimate of Value Including Accessories and Spare parts : RM 7,000.00
Nilai Anggaran Termasuk Aksesori dan Alat-alat Gantian

Premium : RM 288.48
Premium
NCDDiscount Tanpa Tuntutan 15.00% : RM 43.27
-------------------- . .
Gross Premium / Premium Kasar : RM 245.21
Service Tax Cukai Perhidmatan 6.00% : RM 14.71
Stamp Duty Duit Setem : RM 10.00
--------------------
Total Amount Due Jumlah Perlu Dibayar : RM 269.92
===========
Authorised Name Drivers/ Nama Pemandu yang Diberi kuasa
ALL RIDERS

Authorised Drivers/ : AS PER ITEM 5 OF THE CERTIFICATE OF INSURANCE /

Pemandu yang Diberi Kuasa Seperti yang tercatat dalam bilangan 5 sijil Insurans

Compulsory Excess - Damage Claims : RM 100.00

Lebihan Wajib - Tuntutan Kerosakan

Hire Purchase Owners / Employer Loan : NOT APPLICABLE

Pemilik Sewa Beli / Pinjaman Majikan

This Policy is subject to the following endorsement as printed in this Policy or added thereon or attached thereto:
Polisi ini adalah tertakluk kepada pengendorsan yang telah dicetak atau ditambah atau dimasukan kedalamnya
30,2C

Replacing Cover Note No. : V7814500 Issued By/Dikeluarkan Oleh:

Gantian No. Nota Perlindungan
Renewal of Policy No.
Pembaharuan No. Polisi
Date of Proposal or
Declaration
Cadangan atau Pengisytiharan
Date Issue / Time
Tarikh Dikeluarkan / Waktu
BULAT HATI SDN BHD MPI GENERALI INSURANS BERHAD
: D-17-05, MENARA MITRALAND
NO 13A, JALAN PJU 5/1
: 26-07-2021 KOTA DAMANSARA PJU 5,
PETALING JAYA SELANGOR.
: 26-07-2021
03:09:36PM Tel : 0
Fax : -
Mob : 0176953613 ___________________________________________
Authorised Signatory/ Tandatangan Yang Sah

Personal Data Protection Act, 2010

MPI Generali is committed and have put in place a Privacy Policy to safeguard the security and confidentiality of your personal information with us. In using our services and
website, you acknowledge and agree to be bound by the terms of our Privacy Policy which is available at mpigenerali.com.
MPI Generali bertekad dan telah menyediakan suatuPolisi Privasi untuk melindungi keselamatan dan kesulitan maklumat peribadi anda. Dengan mengunakan perkhidamatan
kami dan melayari laman web ini, anda mengiktiraf dan bersetuju dengan syarat-syarat dalam Polisi Privasi kami yang didapati di mpigenerali.com.

Page 1
DUPLICATE COPY MOTORCYCLE STAMP DUTY PAID
JADUAL MOTOSIKAL DUTI SETEM DIBAYAR

Insured Name : HARON BIN NEKMAT Policy No..............................: V7814500

Nama Pemegang No. Polisi
Polisi : PG 56 KAMPONG PARIT GANTONG Account No...........................: AWM07248
Address PARIT SULONG BATU PAHAT JOHOR No. Akaun
Alamat 83500 PARIT SULONG
JOHOR NRIC No...............................: 640616016541
No. Kad Pengenalan
Bus. Regn. No.......................: NA
No. Pendaftaran Perniagaan
Business / Profession: Office Workers Regn. Card No.......................: VEK6075
Perniagaan / Pekerjaan No Kad Pendaftaran
Period Of : a) From 26-07-2021 @ 3:09PM To 25-07-2022 @ 12 midnight
Insurance Dari Hingga
Tempoh Insurans
b) Any subsequent period for which the Insured shall pay and the Company shall agreed to accept a renewal premium
Sebarang tempoh selanjutnya di mana Anda hendaklah membayar dan Kami hendaklah bersetuju menerima premium
pembaharuan.
Type of Cover : Comprehensive Engine No : KF29E8056029
Jenis Perlindungan No. Enjin
Vehicle Registration : VEK6075 Chassis No : PMKKF37A0KB004054
No No Casis
No Pendaftaran
Year of Manufacture : 2019 Cubic Capacity : 149 CC
Tahun Dibuat Keupayaan Enjin
Make & Type of : Honda Vario Seating Capacity : 2
Body Bilangan Tempat
Buatan & Jenis Badan Duduk
Insured's Estimate of Value Including Accessories and Spare parts : RM 7,000.00
Nilai Anggaran Termasuk Aksesori dan Alat-alat Gantian

Premium : RM 288.48
Premium
NCDDiscount Tanpa Tuntutan 15.00% : RM 43.27
-------------------- . .
Gross Premium / Premium Kasar : RM 245.21
Service Tax Cukai Perhidmatan 6.00% : RM 14.71
Stamp Duty Duit Setem : RM 10.00
--------------------
Total Amount Due Jumlah Perlu Dibayar : RM 269.92
===========
Authorised Name Drivers/ Nama Pemandu yang Diberi kuasa
ALL RIDERS

Authorised Drivers/ : AS PER ITEM 5 OF THE CERTIFICATE OF INSURANCE /

Pemandu yang Diberi Kuasa Seperti yang tercatat dalam bilangan 5 sijil Insurans

Compulsory Excess - Damage Claims : RM 100.00

Lebihan Wajib - Tuntutan Kerosakan

Hire Purchase Owners / Employer Loan : NOT APPLICABLE

Pemilik Sewa Beli / Pinjaman Majikan

This Policy is subject to the following endorsement as printed in this Policy or added thereon or attached thereto:
Polisi ini adalah tertakluk kepada pengendorsan yang telah dicetak atau ditambah atau dimasukan kedalamnya
30,2C

Replacing Cover Note No.
Gantian No. Nota Perlindungan
Renewal of Policy No.
Pembaharuan No. Polisi
Date of Proposal or
Declaration
Cadangan atau Pengisytiharan
Date Issue / Time
Tarikh Dikeluarkan / Waktu
: V7814500 Issued By/Dikeluarkan Oleh: MPI GENERALI INSURANS BERHAD
BULAT HATI SDN BHD
: D-17-05, MENARA MITRALAND
NO 13A, JALAN PJU 5/1
: 26-07-2021 KOTA DAMANSARA PJU 5,
PETALING JAYA SELANGOR.
: 26-07-2021
03:09:36PM Tel : 0
Fax : - ___________________________________________
Mob : 0176953613 Authorised Signatory/ Tandatangan Yang Sah

Personal Data Protection Act, 2010

MPI Generali is committed and have put in place a Privacy Policy to safeguard the security and confidentiality of your personal information with us. In using our services and
website, you acknowledge and agree to be bound by the terms of our Privacy Policy which is available at mpigenerali.com.
MPI Generali bertekad dan telah menyediakan suatuPolisi Privasi untuk melindungi keselamatan dan kesulitan maklumat peribadi anda. Dengan mengunakan perkhidamatan
kami dan melayari laman web ini, anda mengiktiraf dan bersetuju dengan syarat-syarat dalam Polisi Privasi kami yang didapati di mpigenerali.com.

Page 2
 ORIGINAL COPY
SALINAN ASAL
........................CERTIFICATE OF INSURANCE .
......................SIJIL INSURANS RTD Code: 20

Road Transport Act, 1987 (Malaysia) Comprehensive RM 7,000.00

Akta Pengangkutan Jalan Raya 1987 (Malaysia)
The Motor Vehicles (Third Party Risks) Rules 1959 (Malaysia) Compulsory Excess - Damage RM 100.00
Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga Dan Pampasan) (KAP 189) (Republik Claims
Singapura) Lebihan Wajib - Tuntutan Kerosakan
The Motor Vehicles (Third Party Risks and Compensation) Rules 1960 (Republic of . .
Singapore) . .
Peraturan Kenderaan Bermotor (Risiko Keatas Pihak Ketiga Dan Pampasan) 1960 (Republik . .
Singapura) ...................C.I.Code/ MY3
The Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei ...................Kod Sijil Insurans:
Darussalam)
Akta Insurans Kenderaan Bermotor (Risiko Keatas Pihak Ketiga) (Kap 90) (Negara Brunei
Darussalam)
CERTIFICATE NO / No Sijil: V7814500 NCD 15.00%
Diskaun Tanpa Tuntutan
1 Index Mark and Vehicle Registration Number / : VEK6075
Tanda Indeks dan Nombor Pendaftaran Kenderaaan
2 Name of Policyholder / Nama Pemegang Polisi
HARON BIN NEKMAT
3 Effective date of Commencement of Insurance for the Purpose of the Act or : 26-07-2021 @ 3:09PM
Ordinance
Tarikh efectif permulaan insuran untuk kegunaan Oridinan
4 Date of Expiry of Insurance / Tarikh Luput Insuran : 25-07-2022 @ 12 midnight
5 Persons or Classes of Persons entitled to drive*
Orang atau Kelas Pihak Yang Dibenarkan Memandu
a) The Policyholder.
b) Any other person who is riding on the Policyholder's order or with his permission.

a) Pemegang Polisi
b) Sesiapa yang menunggang diatas arahan Pemegang Polisi atau dengan kebenarannya.
.
.
.
.
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 yang dibenarkan memandu itu menurut perlesenan atau undang-undang atau peraturan lain bagi memandu Kenderaan Bermotor
dan telah dibenarkan dan tidak hilang kelayakan atau perintah Mahkamah Undang-undang atau atas sebab mana-mana enakmen atau peraturan
berkenaan pemanduan Kenderaan Bermotor.
6 Limitations as to use / had Penggunaan
A) Use for social, domestic and pleasure purposes and by the Policyholder's in person in connection with his business or profession.

The Policy does not cover

A) Use for hire or reward.
B) Use for racing pace-making reliability trial or speed-testing.
C) Use for the carriage of goods (other than samples) in connection with any trade or business.
D) Use for any purpose in connection with the Motor Trade.

Digunakan untuk tujuan sosial, domestik dan persiaran oleh Pemegang Polisi sendiri berkaitan dengan perniagaan atau pekerjaannya.

Polisi ini tidak melindungi

A) Digunakan untuk sewaan atau ganjaran.
B) Digunakan perlumbaan, mengkadar kelajuan ujian kebolehpercayaan, ujian kelajuan.
C) Digunakan untuk membawa barangan (selain daripada sampel) yang berkaitan dengan apa-apa pekerjaan atau perniagaan.
D) Digunaan untuk apa-apa tujuan yang berkaitan dengan Perdagangan Motor
*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 Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei
Darussalam are not included under this heading. Had yang tidak beroperasi oleh Seksyen 95 Akta Pengangkutan Jalan 1987 (Malaysia) atau Seksyen
8 Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga dan Pampasan) (Kap 189) Republik Singapura dan Seksyen 7 Akta Insurans Kenderaan
Bermotor (Risiko Keatas Pihak Ketiga) (Kap 90) Negara Brunei Darussalam tidak termasuk dibawah tajuk ini.
I/We certify that the Policy to which the Certificate 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 Vehicles Insurance (Third Party Risks) Act
(Cap 90) Negara Brunei Darussalam Saya/Kami bersetuju bahawa Polisi di mana Sijil ini dikeluarkan tertakluk di bahawa priviso Bahagian IV Akta
Pengangkutan Jalan 1987 (Malaysia)' Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga & Pampasan) (Cap 189) Republik Singapura dan Akta
Kenderaan Bermotor (Risiko Keatas Pihak Ketiga) (Cap 90) Negara Brunei Darussalam.

Page 3
 MPI GENERALI INSURANS BERHAD
Issued By/Dikeluarkan Oleh:
Account No. : AWM07248 BULAT HATI SDN BHD
No. Akaun D-17-05, MENARA MITRALAND
Date Issue/Time : 26-07-2021 NO 13A, JALAN PJU 5/1
Tarikh 03:09:36PM KOTA DAMANSARA PJU 5,
Dikeluarkan/Waktu PETALING JAYA SELANGOR.
___________________________________________
Tel : 0 Authorised Signatory/ Tandatangan Yang Sah
Fax : -
Mob : 0176953613

Personal Data Protection Act, 2010

MPI Generali is committed and have put in place a Privacy Policy to safeguard the security and confidentiality of your personal information with us. In using our services and
website, you acknowledge and agree to be bound by the terms of our Privacy Policy which is available at mpigenerali.com.
MPI Generali bertekad dan telah menyediakan suatuPolisi Privasi untuk melindungi keselamatan dan kesulitan maklumat peribadi anda. Dengan mengunakan perkhidamatan
kami dan melayari laman web ini, anda mengiktiraf dan bersetuju dengan syarat-syarat dalam Polisi Privasi kami yang didapati di mpigenerali.com.

Page 4
 DUPLICATE COPY
SALINAN PENDUA
........................CERTIFICATE OF INSURANCE .
......................SIJIL INSURANS RTD Code: 20

Road Transport Act, 1987 (Malaysia) Comprehensive R 7,000.00

Akta Pengangkutan Jalan Raya 1987 (Malaysia) M
The Motor Vehicles (Third Party Risks) Rules 1959 (Malaysia) Compulsory Excess - Damage R 100.00
Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga Dan Pampasan) (KAP 189) (Republik Claims M
Singapura) Lebihan Wajib - Tuntutan Kerosakan
The Motor Vehicles (Third Party Risks and Compensation) Rules 1960 (Republic of . .
Singapore) . .
Peraturan Kenderaan Bermotor (Risiko Keatas Pihak Ketiga Dan Pampasan) 1960 (Republik . .
Singapura) ...................C.I.Code/ MY3
The Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei ...................Kod Sijil Insurans:
Darussalam)
Akta Insurans Kenderaan Bermotor (Risiko Keatas Pihak Ketiga) (Kap 90) (Negara Brunei
Darussalam)
CERTIFICATE NO / No Sijil: V7814500 NCD 15.00%
Diskaun Tanpa Tuntutan
1 Index Mark and Vehicle Registration Number / : VEK6075
Tanda Indeks dan Nombor Pendaftaran Kenderaaan
2 Name of Policyholder / Nama Pemegang Polisi
HARON BIN NEKMAT
3 Effective date of Commencement of Insurance for the Purpose of the Act or : 26-07-2021 @ 3:09PM
Ordinance
Tarikh efectif permulaan insuran untuk kegunaan Oridinan
4 Date of Expiry of Insurance / Tarikh Luput Insuran : 25-07-2022 @ 12 midnight
5 Persons or Classes of Persons entitled to drive*
Orang atau Kelas Pihak Yang Dibenarkan Memandu
a) The Policyholder.
b) Any other person who is riding on the Policyholder's order or with his permission.

a) Pemegang Polisi
b) Sesiapa yang menunggang diatas arahan Pemegang Polisi atau dengan kebenarannya.
.
.
.
.
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 yang dibenarkan memandu itu menurut perlesenan atau undang-undang atau peraturan lain bagi memandu Kenderaan Bermotor
dan telah dibenarkan dan tidak hilang kelayakan atau perintah Mahkamah Undang-undang atau atas sebab mana-mana enakmen atau peraturan
berkenaan pemanduan Kenderaan Bermotor.
6 Limitations as to use / had Penggunaan
A) Use for social, domestic and pleasure purposes and by the Policyholder's in person in connection with his business or profession.

The Policy does not cover

A) Use for hire or reward.
B) Use for racing pace-making reliability trial or speed-testing.
C) Use for the carriage of goods (other than samples) in connection with any trade or business.
D) Use for any purpose in connection with the Motor Trade.

Digunakan untuk tujuan sosial, domestik dan persiaran oleh Pemegang Polisi sendiri berkaitan dengan perniagaan atau pekerjaannya.

Polisi ini tidak melindungi

A) Digunakan untuk sewaan atau ganjaran.
B) Digunakan perlumbaan, mengkadar kelajuan ujian kebolehpercayaan, ujian kelajuan.
C) Digunakan untuk membawa barangan (selain daripada sampel) yang berkaitan dengan apa-apa pekerjaan atau perniagaan.
D) Digunaan untuk apa-apa tujuan yang berkaitan dengan Perdagangan Motor
*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 Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei
Darussalam are not included under this heading. Had yang tidak beroperasi oleh Seksyen 95 Akta Pengangkutan Jalan 1987 (Malaysia) atau Seksyen
8 Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga dan Pampasan) (Kap 189) Republik Singapura dan Seksyen 7 Akta Insurans Kenderaan
Bermotor (Risiko Keatas Pihak Ketiga) (Kap 90) Negara Brunei Darussalam tidak termasuk dibawah tajuk ini.
I/We certify that the Policy to which the Certificate 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 Vehicles Insurance (Third Party Risks) Act
(Cap 90) Negara Brunei Darussalam Saya/Kami bersetuju bahawa Polisi di mana Sijil ini dikeluarkan tertakluk di bahawa priviso Bahagian IV Akta
Pengangkutan Jalan 1987 (Malaysia)' Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga & Pampasan) (Cap 189) Republik Singapura dan Akta
Kenderaan Bermotor (Risiko Keatas Pihak Ketiga) (Cap 90) Negara Brunei Darussalam.

Page 5
 MPI GENERALI INSURANS BERHAD
Issued By/Dikeluarkan Oleh:
Account No. : AWM07248 BULAT HATI SDN BHD
No. Akaun D-17-05, MENARA MITRALAND
Date Issue/Time : 26-07-2021 NO 13A, JALAN PJU 5/1
Tarikh 03:09:36PM KOTA DAMANSARA PJU 5,
PETALING JAYA SELANGOR. ___________________________________________
Dikeluarkan/Waktu Authorised Signatory/ Tandatangan Yang Sah
Tel : 0
Fax : -
Mob : 0176953613

Personal Data Protection Act, 2010

MPI Generali is committed and have put in place a Privacy Policy to safeguard the security and confidentiality of your personal information with us. In using our services and
website, you acknowledge and agree to be bound by the terms of our Privacy Policy which is available at mpigenerali.com.
MPI Generali bertekad dan telah menyediakan suatu Polisi Privasi untuk melindungi keselamatan dan kesulitan maklumat peribadi anda. Dengan mengunakan perkhidamatan
kami dan melayari laman web ini, anda mengiktiraf dan bersetuju dengan syarat-syarat dalam Polisi Privasi kami yang didapati di mpigenerali.com.

Page 6
 KOD JPJ / JPJ CODE 20
No Nota Perlindungan/
Cover Note No: V7814500
PMD No:

BORANG CADANGAN INSURANS KENDERAAN / MOTOR INSURANCE PROPOSAL FORM

No Ejen AWM07248 JADUAL/SCHEDULE Tarikh Dikeluarkan/Date of Issue 26-07-2021
Agency No Masa Dikeluarkan/Time of Issue 03:09:36PM
Nama/Name HARON BIN NEKMAT

Alamat PG 56 KAMPONG PARIT GANTONG, PARIT SULONG BATU PAHAT JOHOR,

Address 83500 Parit Sulong Johor
No Telefon/Telephone No: Pejabat/Off:- Jantina [X]Lelaki / Male
Rumah/House:- Bimbit/H/Phone:0167887147 Gender: []Perempuan / Female
Pekerjaan/ Office Workers Tarikh Lahir 16-06-1964 No K.P/No Perniagan 640616016541
Occupation Date of Birth I.C.No./Biz. Regn. No:
Tempoh Perlindungan Dari 03:09:36PM Pada/On 26-07-2021 Sehingga Tengahmalam 25-07-2022
Period of Cover From
No. Kenderaan VEK6075 No. Kad Pendaftaran VEK6075
Registration No. Veh. Regn card No.
Buatan & Model Honda Vario Jumlah Di Insuranskan RM 7,000.00
Make & Model Sum Insured
No. Kenderaan Treler - Jumlah Treler Di Insuranskan RM 0.00
Trailer Registration No. Trailer Sum Insured
No. Enjin KF29E8056029 Diskaun Tanpa Tuntutan (DTT) 15.00%
Engine No. No Claim Discount(NCD)
No. Casis PMKKF37A0KB004054 Premium RM 245.21
Chasis No. Premium
Keupayaan Enjin/Muatan 149 CC Cukai Perkhidmatan & Duti Setem RM 14.71 & RM 10.00
CC/KG/HP Service Tax & Stamp Duty
Bil. Tempat Duduk 2 Jumlah Premium RM 269.92
Seating Capacity Total Premium
Tahun Diperbuat 2019 Lebihan RM 100.00
Year of Manufacture Excess
Perlindungan Tambahan
Additional Benefits
Kegunaan Kenderaan Motor Cycle For Any Use Permit []'A' []'C'
Use of Vehicle
Jenis Perlindungan [X]Komprehensive/Comprehensive [] Pihak Ketiga/Third Party Only
Scope of Cover [] Pihak Ketiga Kebakaran & Kecurian/Third Party Fire & Theft
Pemandu Tambahan: ALL RIDERS Sykt Sewa Beli:
Name Drivers Hire Purchase: NOT APPLICABLE
Taraf Perkahwinan/Marital Status [X]Sudah Berkahwin/Married []Bujang/Single []Lain-lain/Others
Tarikh Pembelian/Purchase - Harga Pembelian/Purchase Price RM 0.00
Date
Dimanakah Kenderaan Anda Terletak pada waktu malam/ Where is the vehicle parked overnight?
[]Di Tepi Jalan/Road Side []Di Halaman Rumah/Within House Compound []Di Luar Rumah/Outside of residents
[]Tempat Letak KeretaParking Lot(Open) []Tempat Letak Kereta(Tertutup)/Parking Lot(Covered) []Lain-lain/Others
Nyatakan alat pencegah kecurian yang terdapat di kenderaan anda?/Describe anti-theft devices fitted in your vehicle?
[] Kunci Stering, Kunci Gear/Stering Gear, Gear Lock etc []Penggera yang dipasang oleh kilang/Factory fitted Alarm []Tidak ada penggera/No Alarm
[] Penggera kecurian,immobiliser,GPS/Alarm, Immobiliser & Global Positioning System(GPS) or Satelite Detection []Lain-lain/others
Adakah kenderaan anda dipasang dengan Sistem Anti-Kunci Brek / Is your vehicle fitted with Anti-Lock Braking System (ABS) [] Ya/Yes [X]Tidak/No
Adakah kenderaan anda dipasang dengan Air Bag? / Is Your vehicle fitted with Air Bag? [] Ya/Yes [X] Tidak/No
Jika Ya, nyatakan bilangan Air Bag dalam Kenderaan tuan / If yes, please statenumber of Air Bag in your car
Sila berikan butir-butir kemalangan dalam tempoh 3 tahun yang lalu (tarikh kemalangan, butir ringkas kemalangan dan amaun tuntutan) / Please furnish
details of claim experience in the last 3 years (date of accident, nature of claim and amount paid)
Untuk Kenderaan Barangan Sahaja / For Goods Carrying Vehicles Only
Jenis barang-barang yang di angkut/Type of goods carried
Nota/Note:Kami tidak akan membayar tuntutan jika kenderaan ini digunakan untuk mengangkut bahan letupan, Petroleum, Toksik, Gas Cecair atau
lain-lain barangan yang merbahaya / We will not pay any claims if the vehicle is used for carriage of Explosive, Petroleum Products, Toxic Substance,
Liquified Gas or and hazardous goods.
Renewal Policy No: Cover Note Type : New Business - Old Vehicle, Old Registration
Tarikh / Date :
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.I/We understand that it is my/our duty to
........................................................... take reasonable care not to make a misrepresentation in answering the question in this Proposal Form and I/we herey
Tandatangan Pencadang / Chop Syarikat declare that I/we have fully and accurately answered the question above.
Signature of proposer/ Company's Chop Personal Data Protection Act, 2010
MPI Generali is committed and have put in place a Privacy Policy to safeguard the security and confidentiality of your

Page 7
personal information with us. In using our services and website, you acknowledge and agree to be bound by the terms of
our Privacy Policy which is available at mpigenerali.com.
MPI Generali bertekad dan telah menyediakan suatuPolisi Privasi untuk melindungi keselamatan dan kesulitan maklumat
peribadi anda. Dengan mengunakan perkhidamatan kami dan melayari laman web ini, andamengiktiraf dan bersetuju
dengan syarat-syarat dalam Polisi Privasi kami yang didapati di mpigenerali.com.

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 NOTIS PENTING

1. Diguna pakai untuk Polisi Kenderaan Persendirian, Polisi Motosikal dan Polisi Akta Motor
A. Kontrak Insurans Pengguna
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 dalam Borang Cadangan ini. Anda dikehendaki menjawab soalan-soalan dalam Borang Cadangan ini dengan
lengkap dan tepat. 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. Kewajipan pendedahan
diatas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami. Sebagai tambahan kepada soalan-
soalan dalam Borang Cadangan 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. 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, apa-apa maklumat yang
dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah.
B. Kontrak Insurans Komersial
Menurut Perenggan 4(1) Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon insurans ini untuk tujuan yang berkaitan dengan
perdagangan, perniagaan atau profesion anda, anda berkewajipan untuk mendedahkan apa-apa perkara yang anda tahu akan mempengaruhi
keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan, dan apa-apa perkara yang munasabah yang boleh dijangka,
jika tidak ia boleh menyebabkan pembatalan kontrak insurans, keengganan atau pengurangan ganti rugi, perubahan terma atau penamatan kontrak
insurans anda. Kewajipan pendedahan diatas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami.
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, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah.

2. Diguna pakai untuk Polisi Kenderaan Perdagangan dan Polisi Motor Plet Perdagangan (Risiko Jalan raya)
Kontrak Insurans Komersial
Menurut Perenggan 4(1) Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon insurans ini untuk tujuan yang berkaitan dengan
perdagangan, perniagaan atau profesion anda, anda berkewajipan untuk mendedahkan apa-apa perkara yang anda tahu akan mempengaruhi
keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan, dan apa-apa perkara yang munasabah yang boleh dijangka,
jika tidak ia boleh menyebabkan pembatalan kontrak insurans, keengganan atau pengurangan ganti rugi, perubahan terma atau penamatan kontrak
insurans anda. Kewajipan pendedahan diatas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami.
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, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah.

IMPORTANT NOTICE

1. Applicable to Private Car, Motorcycle and Act Motor Policy

A. Consumer Insurance Contract
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 this Proposal
Form. You must answer the question in this Proposal Form fully and accurately. 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. The above
duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the
questions in this Proposal Form, 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. 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 this Proposal Form is inaccurate or has changed.
B. Non-Consumer Insurance Contract
Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this insurance for a purpose related to your trade,
business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the
rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it 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. The
above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. You also have a duty to tell
us immediately if at any time after your contract of insurance has been entered into, varried or renewal with us any of the information given in this
Proposal Form is inaccurate or has changed.

2. Applicable to Commercial Vehicle Policy and Motor Trade Policy (Road Risk)
Non-Consumer Insurance Contract
Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade,
business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the
rates and terms to be be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it 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. The
above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. You also have a duty to tell
us immediately if at any time after your contract of insurance has been entered into, varried or renewal with us any of the information given in this
Proposal Form is inaccurate or has changed.

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 NCD UNDERTAKING LETTER
SURAT DISKAUN TANPA TUNTUTAN

I am currently holding a valid *Comprehensive/Third Party policy attached

herewith
Saya adalah pemegang polisi Motor *Komprehensif/Pihak Ketiga yang sah ................................................................................
dengan (current insurer)
and the NCD stated is applicable and correct (Sykt Insurans sekarang)
dan Diskaun Tanpa Tuntutan yang dinyatakan adalah benar
I intend to transfer or claim my %NCD entitlement to vehicle No:
Saya ingin memindahkan atau ......................... %Diskaun Tanpa Tuntutan ke kenderaan .........................
menuntut No.
to be insured with You or purchase a policy from Your Company.

yang mana akan diinsuranskan dengan tuan atau membeli dari syarikat tuan.
I/We hereby confirm that:-
Saya/kami dengan ini mengesahkan:-
(a) the NCD stated on the documents *(Original Policy Schedule / Renewal Notice issued by insurance company / Endorsement
/Certificate of Insurance) is TRUE and correct.
Diskaun Tanpa Tuntutan yang tertera pada dokumen *(Jadual Polisi Asal/Notis Pembaharuan yang dikeluarkan oleh Syarikat
Insurans/Endosmen/Sijil Insuran) adalah betul dan BENAR.
(b) to the best of my knowledge no claim or Action has been lodged / pending or is likely to be taken against me / us under the
policy.
Sepanjang pengetahuan saya, tiada tuntutan atau tindakan telah dilaporkan/tertangguh atau kemungkinan sebarang tuntutan
ke atas saya/kami dibawah polisi ini.
(c) there is no breach of any policy conditions which affects my NCD entitlement.
Tiada sebarang pelanggaran ke atas syarat-syarat yang membolehkan kelayakan Diskaun Tanpa Tuntutan saya terjejas.
(d) I have not and shall not use this entitlement of NCD for any other vehicle/policy.
Saya belum dan tidak akan menggunakan Diskaun Tanpa Tuntutan ini untuk kenderaan/polisi lain.
(e) if the NCD is incorrect, I undertake to pay the difference of premium within 14 working days, failing which I agree the policy
may by cancelled by the company.
Sekiranya Diskaun Tanpa Tuntutan didapati tidak betul, saya akan bertanggungjawab dan berjanji akan membayar kembali
perbezaan premium dalam jangkamasa 14 hari bekerja, yang mana sekiranya saya gagal berbuat demikian saya bersetuju
perlindungan insurans saya akan dibatalkan oleh syarikat
Enclosed is a copy of *(Original Policy Schedule/Renewal Notice issued by the insurance company/Endorsement/Certificate of
Insurance)as evidence of my entitlement.
Disertakan bersama ini salinan *(Jadual Polisi Asal/Notis Pembaharuan yang dikeluarkan oleh syarikat insurans/Endosmen/Sijil
Insurans)
sebagai bukti kelayakan.

...................................................................
Insured's Signature
Tandatangan Pemegang Polisi

Note:
Nota:

1. If the transfer of NCD is between two different vehicles, please enclose the relevant Cancellation/Recovery NCD
Endorsement for verification.
Sekiranya pertukaran Diskaun Tanpa Tuntuan melibatkan dua kenderaan yang berlainan, sila sertakan butiran
pembatalan/Endosmen pembayaran balik Diskaun Tanpa Tuntutan sebagai pengesahan.
2. NCD from Overseas
Diskaun Tanpa Tuntutan dari Luar Negara
Condition: Duly Signed Declaration letter and submit together with the original NCD Letter stating the number
of claims free years.
(Photostat copy is not accepted)

Syarat: Surat akuan yang telah ditandatangani dan diserahkan bersama-sama surat asal Diskaun Tanpa Tuntutan yang
menunjukkan jumlah tahun tanpa tuntutan dibuat.
(Salinan fotostat tidak akan diterima)
* delete whichever is not appropriate
* potong yang mana tidak berkenaan

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 INVOICE

Invoice No. : 21R100367376

Date Issued : 26-07-2021

Insured's Name : HARON BIN NEKMAT

Address : PG 56 KAMPONG PARIT GANTONG

PARIT SULONG BATU PAHAT JOHOR
83500 PARIT SULONG
Type of Policy : Motor Insurance

Account No. : AWM07248

Trans. No. : 00001

Policy No. : V7814500

Period of Cover : 26-07-2021 - 25-07-2022

Description Amount (RM) Total Excl. Serv. Tax(RM) Total Incl.

Serv. Tax(RM) Serv. Tax(RM)

. ___________________________________________________________________________________________
.
Service Tax @ 6.00%
Premium : 245.21 245.21 14.71 259.92
. ___________________________________________________________________________________________
.
Total : 245.21 245.21 14.71 259.92
. ___________________________________________________________________________________________
.
Stamp Duty : . . 10.00
. ________
Total payable : 269.92
.
========

This is a computer generated document and it does not require a signature.

This document shall not be invalidated solely on the ground that it is not signed

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 INTERMEDIARY BILLING

Invoice No. : 21R100367376

Date Issued : 26-07-2021

Insured's Name : HARON BIN NEKMAT

Address : PG 56 KAMPONG PARIT GANTONG

PARIT SULONG BATU PAHAT JOHOR
83500 PARIT SULONG
Type of Policy : Motor Insurance

Account No. : AWM07248 - BULAT HATI SDN BHD

Trans. No. : 00001

Policy No. : V7814500

Period of Cover : 26-07-2021 - 25-07-2022

Description Amount (RM) Total Excl. Serv. Tax(RM) Total Incl.

Serv. Tax(RM) Serv. Tax(RM)

. ___________________________________________________________________________________________
.
Service Tax @ 6.00%
Premium : 245.21 245.21 14.71 259.92
. ___________________________________________________________________________________________
.
Total : 245.21 245.21 14.71 259.92
. ___________________________________________________________________________________________
.
Stamp Duty : . 10.00
Commission 10.00% : 24.52 24.52 . 24.52
.
________
.
Total payable : 245.40
.
========

This is a computer generated document and it does not require a signature.

This document shall not be invalidated solely on the ground that it is not signed

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