Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

ORIGINAL COPY M.X.1

THE SCHEDULE
JADUAL

RTD CODE : 13 STAMP DUTY PAID

DUTI SETEM DIBAYAR ' Date of Issue/Time Tarikh Dikeluarkan/Waktu 03-03-2010 05:11:27PM

PRIVATE CAR EXCLUDING GOODS

PERIOD OF INSURANCE
TEMPOH INSURANS

(a) From 13-03-2010 (both dates inclusive) Dari 13-03-2010 (termasuk kedua-dua tarikh)

E-Cover Note No.

No. Nota Perlindungan

EBP-063827 BP50684-00 1,239.50 0.00 475.10

To 12-03-2011

Hingga 12-03-2011 (b) Any subsequent period for which the Insured shall pay and the Company shall agree to accept a renewal premium. Sebarang tempoh selanjutnya di mana Anda hendaklah membayar, dan Kami hendaklah bersetuju menerima premium pembaharuan.

Account No.
No. Akaun

INSURED
PEMUNYA

Premium Loading 0% NCD 38.33%

YUSLIZA BTE MOHD YUNUS NO 165 JLN BK 5/6 BANDAR KINRARA PUCHONG 47100 PUCHONG
Extra Coverage LLOP 7.50

ADDRESS
ALAMAT

OCCUPATION/TYPE OF BUSINESS
PERNIAGAAN/PEKERJAAN SEWA BELI/PINJAMAN MAJIKAN BUTIR-BUTIR KENDERAAN

OTHERS

HIRE PURCHASE OWNERS/EMPLOYER'S LOAN PARTICULARS OF VEHICLE Make and Type of Body
Buatan dan Jenis Badan

EXCESS
LEBIHAN

0.00

Registration No./Trailer No.

No. Pendaftaran/No. Treler

GROSS PREM SERVICE TAX 0% STAMP DUTY TOTAL DUE AMOUNT PAYABLE(ROUNDED)

771.90 0.00 10.00 781.90 781.90

PROTON SATRIA NEO 1.6 Engine No.

No. Enjin

JLK1975 Engine C.C/Horse Power/Tonnage

Cc Enjin/Kuasa Kuda/Tan

Act.
Akta

41.63

S4PHPE7246 Chassis No.

No. Casis

1,597.00 CC Seating Capacity

Muatan Tempat Duduk

Year of Manufacture
Tahun Dibuat

Sum Insured
Jumlah Diinsuranskan

39,000.00

PL1BS6MRR9G020204 NRIC No./Bus. Regn. No.

No. Kad Pengenalan/No. Pendaftaran Perniagaan

5 Telephone No.
No. Telefon

2009 Regn. Card No.

No. Kad Pendaftaran

Type of Cover
Jenis Perlindungan

750426115060

- / -

6836743

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 ENDT. 2(f) ENDT. 30 ENDT. 100 ENDT. 106 ENDT. W.1 ENDT. 72 NAMED DRIVERS 1. THE POLICYHOLDER 2. JABKITOL BIN ABD JABAR LODGINGCOMPLAINTS & GRIEVANCES IF YOU HAVE ANY COMPLAINTS OF UNFAIR MARKET PRACTICES BYTHE COMPANY, YOU MAY CALL OR WRITE TO : 1.COMPLAINTS UNIT ALLIANZ GENERAL INSURANCE COMPANY (MALAYSIA) BERHAD GROUND FLOOR, BLOCK 2A, PLAZA SENTRAL,JALAN STESEN SENTRAL 5, KUALA LUMPUR SENTRAL, 50470 KUALA LUMPUR. TEL : 03 - 2264 0520 FAX : 03 - 2264 0602 EMAIL : customer.service@allianz.com.my 2.FINANCIAL MEDIATION BUREAU ("FMB") LEVEL 25, DATARAN KEWANGAN DARUL TAKAFUL, NO.4, JALAN SULTAN SULAIMAN, 50000 KUALA LUMPUR. TEL : 03 - 2272 2811 FAX : 03 - 2274 5752 EMAIL : enquiry@fmb.org.my 3.PENGARAH JABATAN KOMUNIKASI KORPORAT BANK NEGARA MALAYSIA TINGKAT 14B, PETI SURAT 10922, 50929 KUALA LUMPUR. TEL : 03 - 2698 8044 (General Line) FAX : 03 - 2693 6919 EXCESS ALL CLAIMS COMPULSORY EXCESS REPLACEMENT PARTS EXCLUSION OF LEGAL LIABILITY TO PASSENGERS - (Private Car Only) INSURER'S AUTHORISED WORKSHOP WARRANTY NO 1 LEGAL LIABILITY OF PASSENGERS FOR ACTS OF NEGLIGENCE

GeographicalArea : Malaysia, Republic of Singapore and NegaraBruneiDarussalam . KawasanGeografi : Malaysia, Republik of Singapura dan Negara BruneiDarussalam Limitationsas to Use / Authorised Driver : As described in the Certificateof Insurance . HadPenggunaan / Pemandu Yang Diberi kuasa : Seperti yang tercatat dalamSijil Insurans 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

Issued By /Dikeluarkan oleh HAAJA ENTERPRISE / HAAJA ENTERPRISE 10-1-1,JALAN SISWA JAYA 1, MEDANIAGA SISWA JAYA, TAMAN SISWA JAYA,PARIT RAJA, BATU PAHAT,JOHOR 86400 Parit Raja TEL : 074532714 FAX : 074531714

03-03-2010

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 2*500*-1077*33V0*1*9-1-4

Page 1

08-03-2011 11:02:46

Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

OFFICE COPY M.X.1

THE SCHEDULE
JADUAL

RTD CODE : 13 STAMP DUTY PAID

DUTI SETEM DIBAYAR ' Date of Issue/Time Tarikh Dikeluarkan/Waktu 03-03-2010 05:11:27PM

PRIVATE CAR EXCLUDING GOODS

PERIOD OF INSURANCE
TEMPOH INSURANS

(a) From 13-03-2010 (both dates inclusive) Dari 13-03-2010 (termasuk kedua-dua tarikh)

E-Cover Note No.

No. Nota Perlindungan

EBP-063827 BP50684-00 1,239.50 0.00 475.10

To 12-03-2011

Hingga 12-03-2011 (b) Any subsequent period for which the Insured shall pay and the Company shall agree to accept a renewal premium. Sebarang tempoh selanjutnya di mana Anda hendaklah membayar, dan Kami hendaklah bersetuju menerima premium pembaharuan.

Account No.
No. Akaun

INSURED
PEMUNYA

Premium Loading 0% NCD 38.33%

YUSLIZA BTE MOHD YUNUS NO 165 JLN BK 5/6 BANDAR KINRARA PUCHONG 47100 PUCHONG
Extra Coverage LLOP 7.50

ADDRESS
ALAMAT

OCCUPATION/TYPE OF BUSINESS
PERNIAGAAN/PEKERJAAN SEWA BELI/PINJAMAN MAJIKAN BUTIR-BUTIR KENDERAAN

OTHERS

HIRE PURCHASE OWNERS/EMPLOYER'S LOAN PARTICULARS OF VEHICLE Make and Type of Body
Buatan dan Jenis Badan

EXCESS
LEBIHAN

0.00

Registration No./Trailer No.

No. Pendaftaran/No. Treler

GROSS PREM SERVICE TAX 0% STAMP DUTY TOTAL DUE AMOUNT PAYABLE(ROUNDED)

771.90 0.00 10.00 781.90 781.90

PROTON SATRIA NEO 1.6 Engine No.

No. Enjin

JLK1975 Engine C.C/Horse Power/Tonnage

Cc Enjin/Kuasa Kuda/Tan

Act.
Akta

41.63

S4PHPE7246 Chassis No.

No. Casis

1,597.00 CC Seating Capacity

Muatan Tempat Duduk

Year of Manufacture
Tahun Dibuat

Sum Insured
Jumlah Diinsuranskan

39,000.00

PL1BS6MRR9G020204 NRIC No./Bus. Regn. No.

No. Kad Pengenalan/No. Pendaftaran Perniagaan

5 Telephone No.
No. Telefon

2009 Regn. Card No.

No. Kad Pendaftaran

Type of Cover
Jenis Perlindungan

750426115060

- / -

6836743

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 ENDT. 2(f) ENDT. 30 ENDT. 100 ENDT. 106 ENDT. W.1 ENDT. 72 NAMED DRIVERS 1. THE POLICYHOLDER 2. JABKITOL BIN ABD JABAR LODGINGCOMPLAINTS & GRIEVANCES IF YOU HAVE ANY COMPLAINTS OF UNFAIR MARKET PRACTICES BYTHE COMPANY, YOU MAY CALL OR WRITE TO : 1.COMPLAINTS UNIT ALLIANZ GENERAL INSURANCE COMPANY (MALAYSIA) BERHAD GROUND FLOOR, BLOCK 2A, PLAZA SENTRAL,JALAN STESEN SENTRAL 5, KUALA LUMPUR SENTRAL, 50470 KUALA LUMPUR. TEL : 03 - 2264 0520 FAX : 03 - 2264 0602 EMAIL : customer.service@allianz.com.my 2.FINANCIAL MEDIATION BUREAU ("FMB") LEVEL 25, DATARAN KEWANGAN DARUL TAKAFUL, NO.4, JALAN SULTAN SULAIMAN, 50000 KUALA LUMPUR. TEL : 03 - 2272 2811 FAX : 03 - 2274 5752 EMAIL : enquiry@fmb.org.my 3.PENGARAH JABATAN KOMUNIKASI KORPORAT BANK NEGARA MALAYSIA TINGKAT 14B, PETI SURAT 10922, 50929 KUALA LUMPUR. TEL : 03 - 2698 8044 (General Line) FAX : 03 - 2693 6919 EXCESS ALL CLAIMS COMPULSORY EXCESS REPLACEMENT PARTS EXCLUSION OF LEGAL LIABILITY TO PASSENGERS - (Private Car Only) INSURER'S AUTHORISED WORKSHOP WARRANTY NO 1 LEGAL LIABILITY OF PASSENGERS FOR ACTS OF NEGLIGENCE

GeographicalArea : Malaysia, Republic of Singapore and NegaraBruneiDarussalam . KawasanGeografi : Malaysia, Republik of Singapura dan Negara BruneiDarussalam Limitationsas to Use / Authorised Driver : As described in the Certificateof Insurance . HadPenggunaan / Pemandu Yang Diberi kuasa : Seperti yang tercatat dalamSijil Insurans 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

Issued By /Dikeluarkan oleh HAAJA ENTERPRISE / HAAJA ENTERPRISE 10-1-1,JALAN SISWA JAYA 1, MEDANIAGA SISWA JAYA, TAMAN SISWA JAYA,PARIT RAJA, BATU PAHAT,JOHOR 86400 Parit Raja TEL : 074532714 FAX : 074531714

03-03-2010

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 2*500*-1077*33V0*1*9-1-4

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Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

RTD CODE : 13

CERTIFICATEOF INSURANCE
SIJILINSURANS
ORIGINAL COPY
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

M.X.1

CERTIFICATE NO.
No.Sijil 1. 2. 3.

EBP-063827
: : :

NCD
DiskaunTanpa Tuntutan

38.33%

Index Mark and Registration Number of Vehicle

TandaIndeks Dan Nombor Pendaftaran Kenderaan

JLK1975

1,597.00 CC

PROTON SATRIA NEO 1.6

Name of Policyholder :
NamaPemegang Polisi

YUSLIZA BTE MOHD YUNUS 13-03-2010

Effective date of the Commencement of Insurancefor the purposes for the Regulations, Ordinanceor Enactment
Tarikhefektif permulaan insuran untuk kegunaan Ordinan

4. 5.

Date of Expiry of the Insurance

TarikhLuput Insuran

12-03-2011

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 Kod Ejen : BP50684-00

e-ASC 2*500*-1077*33V0*1*9-1-4

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Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

Cover Note No. : EBP-063827 CREDIT CARD PAYMENT PLEASE COMPLETE THIS FORM IN FULL Name of Cardholder Please charge to my credit card account Card No Card Expiry Date Issuing Bank Contact Number : ____________________________________________________________ :( ) Visa ( ) MasterCard for RM : ___________________ |__|__|__|__| |__|__|__|__|

: |__|__|__|__| : |__|__| - |__|__|

|__|__|__|__|

: ___________________________________________________________ : |__|__|__| - |__|__|__|__|__|__|__|__|

For Proposer Use only: Payment for : MOTOR CASH PLAN GOLF MASTER MILLION DOLLAR PA ( ( ( ( ) ) ) ) PERSONAL ACCIDENT SPECIAL OCCUPATION PA HOUSEOWNER/HOUSEHOLDER Others (please specify) : ___________ ( ( ( ( ) ) ) )

For Agent Use only: Agent Account Number Motor (MT) Non Motor (NM) Premium Warranty (PW) : BP50684-00 : RM_________________________ : RM_________________________ : RM_________________________ Checked by: Signature Name 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 2*500*-1077*33V0*1*9-1-4

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Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

PLEASE PRINT IN BLOCK LETTERS. BEFORE COMPLETING, READ THE WARRANTIES HEREIN SILA ISI DENGAN MENGGUNAKAN HURUF BESAR DAN BACA SEMUA WARANTI YANG TERKANDUNG DISINI

(Tick [/] where applicable) (Tandakan [/] Yang Berkenaan)

A. DETAILS OF PROPOSER / BUTIR-BUTIR PENCADANG

Name / Nama: Address / Alamat:

YUSLIZA BTE MOHD YUNUS NO 165 JLN BK 5/6 BANDAR KINRARA PUCHONG

Postcode / Poskod:

47100 PUCHONG 26-04-1975

If vehicle is not garaged at the above address, provide postcode of where it is garaged Jika kenderaan tidak disimpan di alamat seperti diatas, nyatakan poskod ia disimpan. Old IC No. / Passport No. / No. Kad Pengenalan Lama / No. Pasport Year Licence Obtained / Tahun Lesen Diperolehi Occupation / Type of Business / Pekerjaan / Jenis Perniagaan New IC No. / No. Kad Pengenalan Baru

Postcode / Poskod:

Date Of Birth / Tarikh Lahir: Gender / Body Corporate / Jantina / Badan Korporat: Marital Status / Taraf Perkahwinan

750426115060

Female Single -, -, -

Driving License Number / No. Siri Lesen Memandu

OTHERS

Business Registration No. / No. Pendaftaran Perniagaan E-Mail Address / Alamat E-Mail

Phone Number / No. Telefon

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

B. SCOPE OF COVER / PERLINDUNGAN

Period of Insurance Required / Tempoh Insurans Dipohon

00:01 AM , 13-03-2010, 12-03-2011

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 Purpose for which vehicle is used / Tujuan Kenderaan digunakan Geographical Location: 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:

New Business - Old Vehicle, Old Registration PRIVATE CAR - PRIVATE USE Others Co. or HP Name / Sykt. Atau Nama Penyewa

C. DESCRIPTION OF VEHICLE / BUTIR-BUTIR KENDERAAN

Make / Model Buatan / Modal Year of Manufacture / Tahun di Perbuat Engine No. / No. Enjin Chassis No. / No. Casis Cubic Capacity / Kuasa Enjin

PROTON SATRIA NEO 1.6 2009 S4PHPE7246 PL1BS6MRR9G020204

Registration No. / No. Pendaftaran Age of Vehicle / Usia Kenderaan Body Type / Jenis Badan Saloon Convertible

Van Coupe

4x4 Others

1,597.00 CC

JLK1975

Log Book No. (Attached Copy) / No. Buku Pendaftaran (lampirkan salinan)

6836743 5

Sum Insured inclusive of: (Air cond) / Nilai Insurans termasuk (Hawa dingin) Road Tax Expiry Date Airbags Installed / Permasangan Beg Angin None

RM 39,000.00 Anti Theft Device Installed / Pemasangan Alat Mencegah Kecurian

Seating Capacity / Muatan Tempat Duduk Without Mechanical Device - Other None

ABS Braking System Installed / 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 THE POLICYHOLDER JABKITOL BIN ABD JABAR New NRIC No / No Kad Pengenalan Baru Sex / Driving Experience (Years) / Jantina / Pengalaman Memandu (Tahun) Occupation / Pekerjaan

e-ASC 2*500*-1077*33V0*1*9-1-4

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Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

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

F. EXTENDED COVERS / PERLINDUNGAN TAMBAHAN LEGAL LIABILITY OF PASSENGERS FOR ACTS OF NEGLIGENCE

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 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 permohonan anda / mengenakan terma khas / membatalkan atau enggan membaharui polisi anda? Jika Ya, nyatakan penjelasan Yes / Ya No / Tidak ______________________________________________________________________________________________________________________________________ insurans menolak Syarikat

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) b) to be bound by terms, conditions, exceptions and operational warranties of the Policy which have been brought to my/our specific attention. 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) b) tertakluk kepada syarat-syarat pengecualian dan kepada waranti polisi yang mana telah dikemukakan kepada pengetahuan saya/kami secara terperinci 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 ______________________________________________ e-ASC 2*500*-1077*33V0*1*9-1-4

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Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

ROAD WARRIOR PROPOSAL FORM THE ROAD WARRIOR INSURANCE P.A. Benefits PAYMENT PER UNIT / PER PERSON RW A. Accidental Death/Permanent Disablement/Loss of both hands or 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) Loss of one foot or one hand or sight of one eye Insanity or loss of four fingers and thumb in one hand/Loss of hearing of both ears or speech Loss of all toes Double Indemnity (for death or permanent disablement if accident occurs during a nationwide public holiday) Medical Expenses Bereavement Cosmetic Surgery Hospital Income (up to 60 days)
RW * *

DPPA RM10,000

RM10,000

B. C. D. E. F. G. H. I.
Note:-

RM5,000 RM5,000 RM2,000 RM20,000 Up to RM1,000 RM500 Up to RM1,000 RM30 per day

RM5,000 RM10,000 RM500.00 RM500.00 -

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. ii. iii. iv. v. vi. vii. 24 hours emergency towing and minor road side repairs Car replacement assistance Arrangement for hotel accommodation Referral to car service centre Referral to doctors and hospitals Legal assistance Emergency message transmission

Table of Premium (RW) Please choose coverage [Tick /] Seating Capacity (incl driver) 4 seats 5 seats 6 seats Each Additional Seat
Please add RM10 for stamp duty.

1 unit RM50 [ RM60 [ RM70 [ RM8 [ ] ] ] ]

2 units RM95 [ RM114 [ RM133 [ RM15 [ ] ] ] ]

3 units RM135 [ RM162 [ RM189 [ RM21 [ ] ] ] ]

4 units RM175 [ RM210 [ RM245 [ RM27[ ] ] ] ]

5 units RM215 [ RM258 [ RM300 [ RM33 [ ] ] ] ]

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.

|__|__|__|__|__|__| DATE e-ASC 2*500*-1077*33V0*1*9-1-4

...................................................... Signature of Proposer

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Allianz General Insurance Company (Malaysia) Berhad

NO 1-2, GROUND FLOOR & 1ST FLOOR JALAN MAJU 1 TAMAN MAJU 83000 JOHOR Tel: 07-4338166 Fax: 07-4332166 Email:info@allianz.com.my

(735426-V)

DECLARATION / LETTER OF UNDERTAKING

AKUAN/SURAT AKUJANJI To : Name & Address of Insured
Nama & Alamat Insured

Kepada

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

YUSLIZA BTE MOHD YUNUS NO 165 JLN BK 5/6 BANDAR KINRARA PUCHONG

Dear Sir,
Tuan,

NCD ENTITLEMENT
KELAYAKAN NCD

: : : (NEW)
(BARU)

VEHICLE NO
NO KENDERAAN

I/C NO (OLD)
NO K/P (LAMA)

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) b) c) d) e)

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.

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.

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.

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.

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. 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

2.

e-ASC 2*500*-1077*33V0*1*9-1-4

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