COVER NOTE

STAMP DUTY PAID

PROTON INSURANCE PROGRAM

Participant Cover Note No. : KDB70431
Account No. : V0037538
LEE SHI LIN Agent Name : SUPERNAU MOTORS TRADING
LOT 1727 LORONG 1C SDN BHD
TAMAN RIVERVIEW
KUCHING Product Type : Private Car - Private Use
93450 SARAWAK Period of Takaful from To (both Dates Inclusive). Any subsequent
period for which the Participant shall pay and the Takaful Operator
shall agree to accept a renewal contribution..

NRIC No : 720922-13-5012 Business Reg No Sum Covered RM 115000.00

Business/Occupation : PRIVATE Other ID No Gross Contribution RM 2154.07
EMPLOYEE Add: Loading 0.00% RM 0.00
Vehicle Information Less: No Claim Discount RM 1184.74
JPJ Document No : 55.00%
Vehicle Reg No TBA Log Book No NIL Flood Relief Allowance(Non- RM 0.00
Tariff) (RM1,000.00)
Make PROTON
Key Care Cover (Non-Tariff) RM 0.00
Model PROTON X50 1.5TGDI FLAGSHIP (A) (RM1,000.00)
Engine No JLH3G15TDNCBA60040 Cover Type COMPREHENSIVE Personal Accident (Non-Tariff) RM 0.00
32 (RM15,000.00)
Chassis No PL1DG2FVRPG088353 Vehicle Type Private Car ______
Year of 2023 License Type Normal Vehicle RM 969.33
Manufacture
Less : Discount/Rebate % RM 0.00
Cubic Capacity 1477 Use For Private Use
Add : Service Tax 6.00% RM 58.16
Seating Capacity 5
Stamp Duty RM 10.00
Financial Interest : HONG LEONG ISLAMIC BANK BHD
Authorised Driver
TOTAL AMOUNT DUE RM 1037.49
1 THE PARTICIPANT 720922-13-5012
2 ANY AUTHORISED DRIVER -
Subject to the following warranties, endorsements and clauses incorporated herein and Excess All Claims RM 0.00
forming part of the Certificate.
Clause Code Clause Name
IMPORTANT NOTICE - APPLICABLE TO ALL CONSUMER PRODUCTS
(Takaful wholly for purposes unrelated to your trade, business or profession)
Where You have applied for this Takaful wholly for purposes unrelated to Your trade, business or profession, You had a duty to take reasonable
care not to make a misrepresentation in answering the questions in the Application Form (or when You applied for this Takaful) i.e. You should
have answered the questions fully and accurately. Failure to have taken reasonable care in answering the questions may result in avoidance of
Your contract of Takaful, refusal or reduction of Your claim(s), change of terms or termination of Your contract of Takaful in accordance with the
remedies in Schedule 9 of the Islamic Financial Services Act 2013. You were also required to disclose any other matter that You knew to be
relevant to our decision in accepting the risks and determining the rates and terms to be applied.

You also have a duty to tell Us immediately if at any time after Your contract of Takaful has been entered into, varied or renewed with Us any of
the information given in the Application Form (or when You applied for this Takaful) is inaccurate or has changed.

Issue Date : 12/05/2023 For and on behalf of

Issue At : S1 Etiqa General Takaful Berhad
Issue By : sharon

Visit www.etiqa.com.my or our nearest branch to obtain the full policy wordings.
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