AIA General Berhad (924363-W)

Menara AIA, 99 Jalan Ampang

50450 Kuala Lumpur
Care Line : 1300 88 1899
Fax : 03-2056 2591

AIA.COM.MY

MOTOR COVER NOTE SM No / NOTA LINDUNG KENDERAAN SM No :

V120027600
CBC REGULATION/ PERATURAN CBC Section 84 (I) of the Financial Services Act 2013: No cover can be granted until the premium has been paid
in accordance with the Regulations issued under the Section. Any person who fails to comply with this Section shall be guilty of an offence and shall
on conviction be liable to a fine not exceeding RM500,000/-. You are therefore advised to pay your premiums.
Seksyen 84 (I) Akta Perkhidmatan Kewangan 2013: Perlindungan tidak akan diberi sehingga premium telah dibayar mengikut peraturan-peraturan
yang dikeluarkan di bawah Seksyen ini.Sesiapa yang gagal mematuhi peraturan ini adalah melakukan suatu kesalahan dan jika disabitkan
kesalahannya boleh didenda tidak lebih daripada RM500,000. Oleh itu anda dinasihatkan supaya membayar premium anda.

The insurance you have purchased is subject to the following transportation laws:
Insurans yang anda beli adalah tertakluk kepada undang-undang pengangkutan berikut:

Road Transport Act, 1987 (Malaysia) The Motor Vehicles (Third Party Risks) Rules, 1959 (Malaysia), The Motor Vehicles (Third Party Risks and
Compensation), Act (Cap 189) Republic of Singapore, The Motor Vehicles (Third Party Risks and Compensation)Rules 1960 Republic of Singapore,
The Motor Vehicle Insurance(Third Party Risks) Act (Cap 90) Negara Brunei Darussalam.
Akta Pengangkutan Jalan 1987(Malaysia), Peraturan Kenderaan Motor (Risiko Pihak Ketiga) 1959 (Malaysia), Kenderaan Motor(Risiko dan
Pampasan Ganti Rugi Pihak Ketiga) Akta (Cap 189) Republik Singapura, Peraturan Kenderaan Motor (Risiko dan Pampasan Ganti Rugi Pihak
Ketiga) 1960 Republik Singapura Akta Insurans Kenderaan Motor(Risiko Pihak Ketiga) Akta (Cap 90) Negara Brunei Darussalam.
Issuance Date/Tarikh dikeluarkan : 28-JUL-2023

Name/Nama : MUZZAMIL MANSOR

New I.C.No /No.K.P.Baru : 800627-08-5593

Business Reg.No / Pendaftaran Perniagaan : - NIL -

I.C No printed on Registration card if differs from New I.C.No /

No.K.P. tercetak pada kad pendaftaran jika berbeza dari No K.P Baru : - NIL -

Passport No / No Pasport : - NIL -

Date of Birth / Tarikh Lahir :27-JUN-1980

Gender / Jantina : MALE / LELAKI

Nationality / : MALAYSIA
Warganegara
B6-10 PANGSAPURI DAMAI, JLN TO
Address / Alamat : TAMAN SRI MUDA, SEK 25,
40400
SELANGOR

Having proposed for insurance and paid the sum of RM346.03 in respect of the Motor Vehicle described in the Schedule below the risk is hereby
HELD COVERED in the terms of the Company's usual form of COMPREHENSIVE/KOMPREHENSIF Policy applicable thereto for the period from
12:01 AM on 29-AUG-2023 to Midnight on 28-AUG-2024 unless the cover be terminated by the Company by notice in writing in which case the
insurance will the reupon cease and the Company will return a proportionate part of the premium already collected for such insurance after due
allowance for the period the Company has been on risk.

Dengan cadangan insurans dan membayar sejumlah RM346.03 berhubung Kenderaan yang disebut di dalam Jadual di bawah, bahawa risiko adalah
DILINDUNGI mengikuti borang biasa Syarikat COMPREHENSIVE/KOMPREHENSIF Polisi yang diterima pakai bagi tempoh dari 12:01 AM pada 29-
AUG-2023 hingga tengah malam pada 28-AUG-2024 melainkan perlindungan tersebut ditamatkan oleh Syarikat secara notis bertulis, maka dalam
keadaan sedemikian insurans tersebut akan tamat dan Syarikat akan mengembalikan bahagian premium bersekadar yang telah dikutip untuk insuran
tersebut selepas mengambilkira tempoh Syarikat berada pada risiko.

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SCHEDULE / JADUAL
NEW INSURANCE / INSURANS BARU

Policy no. / No Polisi : YA015256

Scope of Coverage / Skop Perlindungan : COMPREHENSIVE/KOMPREHENSIF

Use of Vehicle / Kegunaan Kenderaan : DAILY USE

East/ West Malaysia : WEST MALAYSIA/SEMENANJUNG MALAYSIA

Make & Model of Vehicle / Buatan & Model Kenderaan : PERODUA - PERODUA AXIA

Year of make / Tahun dibuat : 2018

Registration No. / No Pendaftaran : VCC139

Capacity / Keupayaan enjin : 998CC

Engine No. / No Enjin : H14C81L

Chassis No. / No Casis : PM2B200S003333982

Sum Insured (RM) / Jumlah Insuran (RM) : RM 15,000.00

Policy Excess (RM) / Lebihan Polisi (RM) : RM 0.00

*Excess is the first amount that must be borne by you for each and every claim that we approve, even if the incident is not your fault.In addition to the above excess, there
is another type of Excess which is the Compulsory Excess of RM400 where it is payable if you or your authorised driver is under the aged of 21, holds a Provisional (P) or
Learner (L) drivers licence or is not named in the Policy Schedule as a named driver. / Ekses adalah amaun pertama yang anda terpaksa tanggung sendiri bagi setiap
tuntutan yang kami luluskan, walaupun kejadian itu bukan salah anda.Sebagai tambahan kepada ekses di atas, ekses Wajib RM400 (tidak dibenarkan untuk dikecualikan)
akan DIKENAKAN jika orang yang memandu Kereta Anda dengan izin Anda adalah di bawah umur 21 tahun, memegang lesen memandu Percubaan (P) atau Sementara
(L); atau tidak dinamakan di dalam Jadual Polisi sebagai Pemandu Dinamakan.

NCB : 55.00% Gross Premium : RM317.01

Service Tax : 6.00% (RM19.02) Stamp Duty (RM) : RM 10.00

Rebate / Rebat : 0.00%

Inclusion of Extra Benefits : 1) SPECIAL PERILS (FLOOD, WINDSTORM AND TYPHOON)

Name Driver(s) : 1) MUZZAMIL MANSOR

2) RASHIDAH BINTI MOHAMED

Hire Purchase / Sewa Beli : - NIL -

Mode of Payment / Cara Pembayaran :

-

CERTIFICATE OF INSURANCE / SIJIL INSURANS

I/We hereby certify that this covering note is issued in accordance with the provisions of part IV of the Road Tax Transport Act, 1987 (Malaysia) The
Motor Vehicle (Third Party Risks and Compensation) Act (Republic of Singapore) and The Motor Vehicle Insurance (Third Party Risks) Act (Cap 90)
Negara Brunei Darussalam.
Saya/Kami dengan ini mengesahkan bahawa nota lindung ini dikeluarkan mengikut peruntukan Bahagian IV Akta Pengangkutan Jalan, 1987
(Malaysia), Akta Kenderaan Motor (Risiko dan Pampasan Ganti Rugi Ketiga)(Republik Singapura) dan Akta Insurans Kenderaan Motor(Risiko Pihak
Ketiga) (Cap 90) Negara Brunei Darussalam.

Producer Code / Kod Ejen : BJK01

Producer Name / Nama Ejen : BULAT HATI SDN.BHD.

Please contact BULAT HATI SDN.BHD. or AIA HELPLINE 1300 88 1899 (GENERAL INSURANCE) if you have not received your
policy/endorsement within 30 days from 28-JUL-2023

For and on behalf of / Untuk dan Bagi Pihak

AIA General Berhad

**This is computer generated document and no signature is required.

Ini adalah cetakan computer dan tandatangan tidak diperlukan.

ECN/2023/2024/8

Writing Agent: BJK01 BULAT HATI SDN.BHD.

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