RTD Code:08

PRIVATE CAR SCHEDULE / JADUAL KERETA PERSENDIRIAN

auto 365 Comprehensive Premier
The Insured / Pemegang Polisi Policy No. / No. Polisi
JVE1349698 01-C1
SHEELA A/P SRAGUNATHAN
Account No. / No . Akaun
NO.6687 JLN MELATI 9 529900-00
INDAHPURA Type of Cover / Jenis Perlindungan
81000 KULAI COMPREHENSIVE PREMIER
Period of Insurance / Tempoh Insurans
From / Dari 00:00:01 AM 08-10-2021 To / Hingga 07-10-2022
Bus. Regn. No / Premium / Premium RM 1,912.95
Occupation / Pekerjaan No Pendaftaran Perniagaan
SALES EXECUTIVE - 1,912.95
NCD / Diskaun Tanpa Tuntutan 25.00% 478.24
Wef / Berkuatkuasa dari 08-10-2021
I.C. No. / No.Kad Pengenalan 1,434.71
Optional Cover
971113106306
Windscreen Damage (Tempered/Laminated Glass Inclusive T 225.00
Hire Purchase Owner / Pemilik Sewa Beli Labour Cost) / Kerosakan Cermin Kenderaan (Pengubahan T
Cermin / Cermin Berlapis Termasuk Kos Buruh) RM T
MAYBANK BERHAD
1,500.00T
Make & Type of Body / Buatan & Jenis Badan T
TOYOTA VIOS G / 4D SEDAN Gross Premium / Premium Kasar 1,659.71

Service Tax / Cukai Perkhidmatan 6.0 % 99.58

Registration No. / Excess / Lebihan Regn. Card No. / No.Kad Stamp Duty / Duti Setem 10.00
No.Pendaftaran Pendaftaran
0.00
VFM1311 -

Carrying or Seating Tonnage / C.C./ Watt Sum Insured / Jumlah

Capacity Incl. Driver / Tan / Keupayaan Enjin Diinsuranskan (RM)
Muatan Tempat Duduk 1496.00 CC
Termasuk Pemandu 71,000.00
Year of Manufacture /
5 Tahun Diperbuat (Agreed Value)
2020

Engine /Motor No. / No . Enjin / Motor

2NR0P06851
Chassis No. / No. Casis Trailer / Treler
PN153SYF103086623 -
Named Driver / Pemandu Yang Dinamakan

ANY AUTHORISED DRIVER

Note : Compulsory excess will be applied for named driver under 21 years old /
Provisional (P) or Learner (L) driver’s licence / unnamed driver. / Ekses wajib
akan dikenakan untuk pemandu yang dinamakan di bawah umur 21 tahun /
pemegang lesen memandu Percubaan (P) atau Pelajar (L) / Pemandu yang
tidak dinamakan.
Subject to IMPORTANT NOTICE: Your duty as the Owner of the vehicle as attached. Total Due / Jumlah Berbayar RM 1,769.29

Geographical Area : Malaysia , Republic of Singapore and Negara Brunei Darussalam. / Kawasan Geografi : Malaysia, Republik Singapura dan
Negara Brunei Darussalam.
Limitations as to Use / Authorised Driver : As described in the Certificate of Insurance. / Had Penggunaan / Pemandu Yang Diberi Kuasa : Seperti
yang tercatat dalam Sijil Insurans.
Replacing Cover Note No./ - Issued By / Dikeluarkan Oleh : For / untuk
Gantian No. Nota MENG CHONG MOTOR AmGeneral Insurance Berhad
Perlindungan ENTERPRISE
Renewal of Policy No./ - NO.1, JALAN BUNGA ROS
Pembaharuan No.Polisi TAMAN SRI KULAI BARU
Date of Proposal or 28-09-2021 81000 KULAI
Declaration / JOHOR DARUL TAKZIM
Tarikh Cadangan atau Tel : 07-6633345 ,013-7722345
Pengisytiharan Fax : 07-6633700 Authorised Signature /
Date of Issue / Time 28-09-2021 12:17:59 PM Tandatangan Yang Diberi Kuasa
Tarikh Dikeluarkan / Waktu 238210280921W713
Note: / Nota: No refund of premium for any cancellation of policy if premium is charged on minimum premium / Tiada bayaran balik premium bagi sebarang pembatalan polisi sekiranya premium
yang dikenakan adalah premium minima.

Page 1 10-05-2022 06:11:27 PM

 12JV2NPN970959-2

Policy Document No./ UW-PW-S009(E)(MT)

No.Dokumen Polisi: REV: B
C.I. Code / M.X.1
Kod Sijil Insurans:

CERTIFICATE OF INSURANCE / SIJIL INSURANS

AKTA PENGANGKUTAN JALAN RAYA 1987 (MALAYSIA)
ORIGINAL COPY / PERATURAN KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA) 1959 (MALAYSIA)
AKTA KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA DAN PAMPASAN) (KAP 189) REPUBLIK SINGAPURA RTD Code :08
SALINAN ASAL PERATURAN KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA DAN PAMPASAN 1960 (REPUBLIK SINGAPURA)
AKTA INSURANS KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA) (KAP 90) NEGARA BRUNEI DARUSSALAM
Certificate No. / No. Sijil
JVE1349698 01-C1 Excess : RM 0.00 Sum Insured : RM 71,000.00 (Agreed Value)
1. Index Mark and Registration Number of Vehicle / Tanda Indeks dan No. Pendaftaran Kenderaan
VFM1311 NCD : 25.00% Wef : 08-10-2021
2. Name of Insured / Nama Pemegang Polisi
SHEELA A/P SRAGUNATHAN
3. Period of Insurance / Tarikh Insurans
From / Dari 00:00:01 AM 08-10-2021 To / Hingga 07-10-2022
4. Persons or Classes of Persons entitled to drive / Orang atau kelas orang yang layak memandu:*
a) The Insured.
b) Any other person who is driving on the Insured's order or with his/her permission.
a) Pemegang Polisi.
b) Sesiapa yang memandu atas 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 atas perintah
Mahkamah Undang-undang atau atas sebab mana-mana enakmen atau peraturan berkenaan pemanduan kenderaan bermotor.
5. Limitations as to use / Had Penggunaan*
Use only for social, domestic and pleasure purposes and for the insured`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.
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.
* 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 ditakwilkan tidak berkuatkuasa oleh Seksyen 95 Akta Pengangkutan Jalanraya (Malaysia),1987 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 HEREBY CERTIFY that the policy to which this certificate relates is issued in accordance 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 Vehicles Insurance (Third Party
Risks) Act (Cap 90) Negara Brunei Darussalam. / SAYA / KAMI DENGAN INI MENGESAHKAN bahawa polisi yang melaluinya sijil ini dikeluarkan adalah
selaras dengan peruntukan Bahagian IV Akta Pengangkutan Jalan, 1987 (Malaysia), Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga dan
Pampasan) (Kap 189) Republik Singapura dan Akta Insurans Kenderaan Bermotor (Risiko Keatas Pihak Ketiga) (Kap 90) Negara Brunei Darussalam.

IMPORTANT NOTICE: Your duty as the Owner of the vehicle. Failure to comply to the below may result your
claim to be declined.
(1) The insured will have to take all reasonable care to secure the vehicle from loss or damage.
(2) Report to the police for all incidents. For road accident, you have to report to the police within 24 hours. for / untuk AmGeneral Insurance Berhad
(3) Notify us in writing within 7 days after the incident and complete the claim form in full and return it to us (Incorporated in Malaysia / Ditubuhkan di Malaysia)
with the related documents within 21 days from your notification's date. Approved Insurers / Penanggung Insurans Yang Dibenarkan
(4) You must obtain our consent in writing before you repair your vehicle or incur any expenses.
(5) For private car own damage claim - In the event of claim, repairs must be conducted by our
approved repairer.
(6) When incident happen, you need to collect these details :
(a) all drivers e.g full name, residential address and contact number
(b) all vehicles e.g. make and model, registration number, and insurance details
(c) date, time and location of the incident
(d) description of the incident and
(e) report to us immediately
(f) report to us for any claims made by another person against you and send us the notices and Authorised Signature /Tandatangan Yang Diberi Kuasa
letters within 14 days from the receipt of the documents.
(7) Do not negotiate or settle any claims made against you, unless you have our consent in writing.
(8) We will have full discretion in the conduct, defence and/or settlement of any claim.
Agent Code / Kod Ejen: 529900-00
N.B. (i) We have the right to cancel this policy by giving you 14 days’ notice in writing by
registered post to your last known address in our records.
(ii) Betterment – In the event your vehicle age is 5 years and above, this policy is subject to rate of betterment.
(iii) You need to read this policy carefully, and if any error or incorrect description is found herein, or
if the cover is not in accordance with your wishes, you should inform us immediately and return this policy to us for alteration.

Important Notice / Kenyataan Penting :

* For environmental conservation, we have adopted paper less printing concept. Please log on to our website to view the Bahasa Malaysia language policy wordings, terms and conditions and exclusion.
For further enquires, please contact your insurance intermediary or our Customer Contact Centre. /Untuk pemeliharaan alam sekitar, kami telah mengaplikasikan konsep tanpa percetakan. Sila layari laman
web kami untuk rujukan da / atau mencetak kandungan polisi, terma-terma, syarat-syarat dan pengecualian dalam Bahasa Melayu. Untuk pertanyaan lanjut, sila hubungi ejen insurans anda atau Pusat
Khidmat Pelanggan kami.
* You are advised to read and understand the summary of this product as contained in the Product Disclosure Sheet on our website. /Anda dinasihati supaya membaca dan memahami ringkasan produk ini
seperti yang tertera di dalam Lampiran Pemberitahuan Produk yang boleh didapati dilaman web kami.
0917

Page 2 10-05-2022 06:11:27 PM

 Invoice
Invois
COPY

Invoice No. : SST-09-21-08250908 Date : 28-09-2021

No. Invois Tarikh

Name : SHEELA A/P SRAGUNATHAN

Nama

Address : NO.6687 JLN MELATI 9

Alamat INDAHPURA
81000 - KULAI

Agent Name : MENG CHONG MOTOR Account No. : 529900-00

Nama Ejen ENTERPRISE No. Akaun

Policy/Endorsement No. : - Cover Note No. : JVE1349698

No. Polisi/Endorsemen No. Nota

Class of Policy : PRIVATE CAR EX GOODS

Jenis Insurans

Period of Insurance : From 08-10-2021 To 07-10-2022

Tempoh Insurans

No. / No Description / Deskripsi Total / Jumlah (RM)

1 Gross Premium / Premium Kasar 1,659.71
2 Service Tax / Cukai Perkhidmatan 6% 99.58
3 Stamp Duty / Duti Setem 10.00
4 Total Payable (OTC) / Jumlah Berbayar Di Kaunter 1,769.30
5 Total Payable / Jumlah Berbayar 1,769.29

AmGeneral Insurance Berhad

This is computer generated. No signature is required.

Ini adalah cetakan komputer . Tandatangan tidak diperlukan.

Page 3 10-05-2022 06:11:27 PM

INSURED NAME : SHEELA A/P SRAGUNATHAN
VEHICLE NO : VFM1311
COVER NOTE NO : JVE1349698
PRIVACY CLAUSE

1.0 PRIVACY CLAUSE

1.1 You confirm that you have read, understood and agree to be bound by the Privacy Notice of AmGeneral Insurance
which is available at our website and the clauses herein, as may relate to the processing of your personal
information. For the avoidance of doubt, you agree that the said Privacy Notice shall be deemed to be incorporated
by reference into this policy.
1.2 In the event you provide personal and/or financial information relating to third parties, including information relating
to your next-of-kin and dependents, for the purpose of operating the Insurance Policy with AmGeneral or otherwise
subscribing to AmGeneral's products and services, you:
a. confirm that you have obtained their consent or are otherwise entitled to provide the information to
AmGeneral and for AmGeneral to use it in accordance with this Insurance Policy;
b. agree to ensure that the personal and financial information of the said third parties is accurate and
update AmGeneral in writing in the event of any change to the said personal and financial information;
and
c. agree to AmGeneral's right to terminate the Insurance Policy should such consent be withdrawn by any
of the said third parties
1.3 Even after you have provided AmGeneral with any information, you have the option to withdraw the consent given
earlier. In such instances, AmGeneral will have the right to not provide or discontinue the provision of the Insurance
Policy that is/are linked with such information.
1.4 You agree that the Company and its related companies may contact you about products and services and offers,
which the Company and its related companies believe may be of interest to you, through various channels of
communication.
1.5 In the event you do not wish to consent to use your personal data to receive marketing of products and services by
the Company and its related companies, you may contact AmGeneral as per below details or you may contact
AmGeneral's nearest branch to you:
Customer Service Executive, Customer Contact Centre
Telephone No E-Mail

AmAssurance 1 800 88 6333 customer@amassurance.com.my

Kurnia Insurans 1 800 88 3833 customer@kurnia.com

1.6 AmGeneral reserves the right to amend this Section from time to time at AmGeneral's sole discretion by providing
notice to you.
VEHICLE INSURED VALUE
1.0 IF YOUR POLICY IS AN 'AGREED VALUE' POLICY
1.1 Your vehicle is insured based on an agreed value.
1.2 In the event of total loss or theft, the maximum amount that we will pay is up to the sum insured as shown in the
schedule.
2.0 IF YOUR POLICY IS A 'MARKET VALUE' POLICY
2.1 Your vehicle is insured based on market value.
2.2 In the event of loss or theft, the maximum amount that we will pay is up to the market value of the vehicle which will
be determined at the time of loss or the sum insured as shown in the schedule; whichever is lesser.

2.3 It is important to insure your vehicle with the appropriate market value. Below are the effects of over-insurance and
under-insurance when an incident happens and giving rise to a claim:
a. Over-insurance : When a claim arises, the maximum amount that we will pay you is up to the market
value of your vehicle even if your vehicle's sum insured is higher than the market
value.
b. Under-insurance : When claim arises, we will only bear part of the loss in proportion to the difference
between the market value and the sum insured. The balance has to be borne by you
if the under-insured amount is more than 10% of the market value.

Page 4 10-05-2022 06:11:27 PM

 Privacy Notice

Personal Data Protection Act 2010 (“PDPA”)

In line with PDPA, AmBank Group is committed to protect and safeguard customers’ Personal Data when entering into any
commercial transaction with AmBank Group.

Throughout this Privacy Notice, the following are the definitions of the terms used:

 AmBank Group refers to AMMB Holdings Berhad and all its subsidiaries and associate companies including but not limited to
AmBank (M) Berhad, AmBank Islamic Berhad, AmInvestment Bank Berhad, AmFunds Management Berhad, AmFutures Sdn
Bhd, AmIslamic Funds Management Sdn Bhd, AmCards Services Berhad, AmGeneral Insurance Berhad, AmMetLife
Insurance Berhad and AmMetLife Takaful Berhad.

 Personal Data refers to any information in respect of commercial transactions which is being processed and recorded that
relates directly or indirectly to a Data Subject, who is identified or identifiable from that information. This includes any Sensitive
Personal Data and expression of opinion about the Data Subject but does not include any information that is processed for the
purpose of a credit reporting business carried on by a credit reporting agency under the Credit Reporting Agencies Act 2010.
Examples of Personal Data include customer’s name, identity card or passport number, address, occupation, contact details,
account details or financial information.

 Sensitive Personal Data refers to any Personal Data consisting of information as to the physical or mental health, condition,
political opinions, religious beliefs or other beliefs of a similar nature.

 Unless expressly defined herein and where the context requires, all capitalized expressions shall have the same meaning
ascribed to it in the PDPA.

Purpose of Collecting Personal Data

In rendering services to customers, AmBank Group may be required to process customers’ Personal Data for any of the following
purposes:

(a) Assessment of customers’ eligibility or suitability for AmBank Group’s products applied for and verification of identity or
financial standing through credit reference checks;
(b) Notification and/or update on new features or development of products and services;
(c) Competitions, promotions, campaigns, offers and etc. from AmBank Group or third party business partners which customers
have participated;
(d) Account management and maintenance including regular updates, consolidation and improving accuracy of records;
(e) Research for analytical purposes based on transactions/use of products and services for better understanding of current and
future financial/investment needs;
(f) Enforcement of AmBank Group’s rights to recover any debt owing, including transfer or assignment of rights, interests and
obligations;
(g) Any other purpose(s) that is required or permitted by any law, regulation, standard, guideline and/or by relevant regulatory
authorities.

Sources of Personal Data

In providing Personal Data related to third parties to AmBank Group (such as next of kin or nominees), the provider of such
Personal Data confirms that consent has been obtained or that he/she is entitled to provide the Personal Data of those parties.

(a) Information provided in application forms when using AmBank Group’s products or services, when transacting accounts, when
using online or electronic services, when taking part in customer surveys, competitions, promotions and during performance of
financial reviews;
(b) Verbal, written and/or electronic communications with AmBank Group or its authorised agents;
(c) Third parties connected to customers, such as their employer, joint account holder, security providers and guarantor(s), other
partners in a partnership, or through AmBank Group’s corporate customers or corporate security providers where the customer
is a director, shareholder, officer or authorised signatory/person;
(d) Images captured by closed circuit television (CCTV) cameras at AmBank Group’s branches, office premises or third party
premises (where self-service terminals are located), when visiting AmBank Group branches or office premises or self-service
terminals at third party premises;
(e) Credit reporting agencies and publicly available sources such as through searches at relevant government authorities or
agencies; and/or
(f) Any other sources which customers have given consent for the intended purposes.

Disclosure of Personal Data

AmBank Group may be required to disclose customers’ Personal Data to the following third parties:
(a) Its agents, service providers, vendors, financial institution(s) and /or professional advisers who assist us in processing,
administering, outsourcing, fulfilling transactions or providing services to customers on its behalf, or to fulfill value added
services that customers have requested;
(b) Its external professional advisors and consultants who provide services to it, for the purposes of its business, operational, legal
and regulatory requirements;
(c) any person(s) authorised or appointed by customers to give instructions to AmBank Group on customers’ behalf such as
customers’ agents, accountants, auditors, lawyers, financial advisers, brokers and intermediaries;
(d) any guarantor(s), security provider(s) or any person(s) intending to settle any moneys outstanding under the facility(ies)
granted by AmBank Group to customers;
(e) any third party(ies) arising from the restructuring of facility(ies) granted to you, sale of debts, acquisition or sale of any
company by AmBank Group provided that the recipient uses customers’ data for the same purpose(s) as it was originally
supplied to and/or used by AmBank Group;
(f) merchants and electronic fund transfer facilitators related to any credit/debit card(s) issued to customers by AmBank Group;
(g) any rating agency(ies), credit reporting agencies, insurer(s), insurance broker(s), re-insurers, loss adjusters, or direct/indirect
provider(s) of credit protection and in the event of default of a facility granted to customers, to debt collection agencies; and/or
(h) with other entities within AmBank Group for products and services that may be of interest to customers;
(i) any competent authority(ies) and/or regulator(s), for the performance of their functions;
(j) any information-sharing systems for fraud prevention and detection, including but not limited to Fraud Intelligence System
(FIS), an information-sharing system which utilizes analytical techniques for fraud prevention and detection, which is operated
by Insurance Services Malaysia Berhad (or any other company engaged for the operation of the FIS from time to time); and/or
(k) any association, federation or any other regulated body incorporated in the interest of insurance industry.

Rights of Data Subject

Obligatory and voluntary Personal Data may differ for various products and services as indicated in the application forms.
Customers may notify AmBank Group in writing to withdraw consent or to cease/begin processing Personal Data, giving AmBank
Group a reasonable period of time to carry out such request.

However, in the event the customer chooses to withdraw consent during an existing contractual agreement with AmBank Group
which may result in its inability to continue the relationship, AmBank Group reserves the right to continue processing customer’s
personal data in accordance with contractual or the applicable operational, audit, investigation, legal, regulatory, tax or accounting
obligations until all obligations are fulfilled.

Customers can access and/or make changes to their Personal Data by completing the Personal Data Request Form available at
AmBank Group branches or website subject to relevant processing fees, where applicable and AmBank Group shall notify
customers the reasons if such request cannot be acceded to. Customers may visit AmBank Group’s nearest branch or contact the
following for enquiries:

Customer Service Executive, Customer Contact Centre

Telephone No E-Mail
AmAssurance 1 800 88 6333 customer@amassurance.com.my
Kurnia Insurans 1 800 88 3833 customer@kurnia.com

Security of Personal Data

AmBank Group places great importance in ensuring the security and confidentiality of its customers’ Personal Data. As such,
AmBank Group regularly reviews and implements up-to-date technical and organisational security measures when processing
customers’ Personal Data. Further information on security controls is available at our Website Security Statement at
www.ambankgroup.com.

Retention of Personal Data

Customers’ Personal Data will be retained in accordance with this Privacy Notice and/or the terms and conditions of agreement(s)
with AmBank Group for the duration of the relationship or for such period as may be necessary to protect the interest of both
AmBank Group and the customers. Such retention is also necessary as required by law or in accordance with relevant internal
policies.

Revisions to Privacy Notice

This Privacy Notice may be revised from time to time and notice of such revision shall be posted on website and/or other means of
communication deemed suitable by AmBank Group.

(Last updated: 8 September 2020)

 LETTER OF UNDERTAKING
To / Kepada : AmGeneral Insurance Berhad
Level 5, Menara Shell,
No. 211, Jalan Tun Sambanthan,
50470 Kuala Lumpur
Tel 1 800 88 3833 Email customer@kurnia.com Website www.kurnia.com

From / Daripada : SHEELA A/P SRAGUNATHAN

NO.6687 JLN MELATI 9
INDAHPURA
81000 KULAI

Date / Tarikh : 28-09-2021

Dear Sir / Tuan / Puan,

NCD Entitlement / Kelayakan Diskaun Tanpa Tututan : 25.00%

Vehicle No / Nombor Kenderaan : VFM1311
I/C No. (Old/New) / Nombor Kad Pengenalan (Lama/Baru) : 971113106306

I am currently holding a valid *COMPREHENSIVE PREMIER motor policy with

__________________________________________________________ (Current Insurer).

I intend to transfer or claim my 25.00% NCD entitlement to a Vehicle No. VFM1311 to be insured with You or purchase a policy from Your Company.

I hereby confirm that:-

(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.

(b) there is no breach of any policy condition(s) which affects my NCD entitlement.

(c) I have not and shall not use this entitlement of NCD for any other vehicle / policy.

(d) if the NCD is incorrect, I undertake to pay the difference of premium within 14 working days, failing which I agree the policy shall be
cancelled by the company.

Ketika ini saya merupakan pemegang sah * Komprehensif Premier polisi motor dengan _______________________________________
(Penanggung insurans sekarang).

Saya ingin memindahkan atau menuntut 25.00% kelayakan Diskaun Tanpa Tuntutan saya ke kenderaan bernombor
VFM1311 untuk diinsuranskan dengan Anda atau membeli polisi daripada syarikat Anda.

Saya dengan ini mengesahkan bahawa:-

(a) 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) tiada perlanggaran pada mana-mana syarat polisi yang boleh menjejaskan kelayakan Diskaun Tanpa Tuntutan saya.

(c) Saya belum dan tidak akan menggunakan kelayakan Diskaun Tanpa Tuntutan ini untuk mana-mana kenderaan/polisi yang lain.

(d) 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.

(Insured Signature / Tandatangan pihak yang 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 claims free years must be submitted.
Surat Akujanji yang ditandatangani sewajarnya dan surat pengesahan asal Diskaun Tanpa Tuntutan yang menyatakan bilangan tahun
bebas tuntutan mestilah disertakan.

* delete whichever is not applicable.

* potong yang mana tidak berkenaan.
 Service Tax Registration No : B16-1808-31015443

MENG CHONG MOTOR Agency Code : 529900-00

AmGeneral Insurance Berhad (44191-P) NO.1, JALAN BUNGA ROS, TAMAN SRI KULAI BARU,
A member of the AmBank Group 81000 KULAI 07-6633345 ,013-
JOHOR DARUL TAKZIM

MOTOR INSURANCE PROPOSAL FORM / BORANG CADANGAN INSURANS MOTOR

Date/time issued (dd/mm/yyyy) / Tarikh/masa dikeluarkan (hh/bb/tttt) 28-09-2021 12:17:59 PM

IMPORTANT NOTICE / NOTIS PENTING

1. STATEMENT PURSUANT TO FINANCIAL SERVICE ACT 2013, 1. MENURUT AKTA PERKHIDMATAN KEWANGAN 2013, SEKSYEN
SECTION 129, SCHEDULE 9, PARA 5: It is the duty of the customer to 129, JADUAL 9, PERENGGAN 5: Adalah menjadi kewajipan pengguna
take reasonable care not to make a misrepresentation to the licensed untuk mengambil penjagaan munasabah untuk tidak membuat salah
insurer when answering any question which the insurer may request that nyataan kepada penanggung insurans berlesen semasa menjawab apa-apa
are relevant to the decision of the insurer whether to accept the risk or not soalan yang diperlukan yang berkaitan dengan keputusan penanggung
and the rates and terms to be applied. 2. YOUR ATTENTION IS DRAWN insurans sama ada untuk menerima atau tidak risiko dan kadar dan terma
TO SECTION 84 OF THE FINANCIAL SERVICES ACT 2013: It has been yang hendak dipakai. 2. PERHATIAN ANDA ADALAH DIARAH KEPADA
prescribed by law that insurance cover shall only be issued by insurers or SEKSYEN 84 AKTAPERKHIDMATAN KEWANGAN 2013: Sebagaimana
their agents on a 'cash before cover' basis, therefore premiums must be ditentukan oleh undang-undang perlindungan insurans akan hanya
paid before the Company issues you with a motor insurance cover note or dikeluarkan oleh syarikat insurans atau ejen berdasarkan pada bayaran
policy. Payment must be made by cash or credit card. Please insist on a tunai sebelum perlindungan insurans diberi, oleh yang demikian, premium
receipt for the premium paid as proof of payment for future reference. 3. mestilah dibayar sebelum pihak Syarikat mengeluarkan nota perlindungan
Passenger Liability Cover -If you intend to drive your vehicle into the atau polisi insurans motor. Bayaran hendaklah dibuat secara tunai atau kad
Republic of Singapore, you are required by Singapore’s law to have cover kredit. Sila dapatkan resit sebagai bukti pembayaran telah dibuat untuk
for ‘Legal liability to passengers (LLP)’ and you can purchase this cover rujukan dimasa hadapan.3. Perlindungan Liabiliti Penumpang- Jika anda
under ‘optional cover’ which provides a limited cover for your liability for bercadang untuk memandu kenderaan anda ke Republik Singapura, anda
death and bodily injury of passenger(s). 4. Product Disclosure Sheet dikehendaki di bawah undang-undang Singapura untuk mempunyai
(PDS) can be obtained through our website. You are advised to read the ‘Perlindungan liabiliti penumpang (PLP)’ dan anda boleh membeli
PDS before you take out insurance policy. 5. Privacy Notice:A full version perlindungan ini di bawah ‘perlindungan opsyenal’ yang menyediakan
of the Privacy Notice of AmGeneral Insurance Berhad is available on our perlindungan terhad bagi liabiliti anda terhadap kematian dan kecederaan
website at www.amgeneralinsurance.com for your further reference. tubuh badan penumpang.4. Lampiran Pemberitahuan Produk (PDS)boleh
didapati di laman web kami. Anda adalah dinasihati untuk membaca PDS
sebelum anda memutuskan untuk mengambil polisi insurans.5. Notis
Privasi:Versi lengkap Notis Privasi AmGeneral Insurance Berhad boleh
didapati di laman web kami di www.amgeneralinsurance.com untuk rujukan
lanjut.

DETAILS OF PROPOSER / BUTIR-BUTIR PENCADANG

Name of proposer / Nama pencadang SHEELA A/P SRAGUNATHAN

Correspondence address / Alamat surat-menyurat NO.6687 JLN MELATI 9

INDAHPURA

81000 Nationality / Warganegara

NRIC No./Passport No./Business registration No. / No. Kad Date of birth/

pengenalan baru/No. Pasport/No. pendaftaran syarikat 971113106306 / - Tarikh lahir 13-11-1997

Occupation/Trade / Pekerjaan/Perdagangan SALES EXECUTIVE

Nature of business / Jenis perniagaan

Tel. no (hse) / No. tel (rumah) Tel. no (off) / No. tel (pejabat)

Handphone no. / No. tel bimbit 0137742345 Email / E-mel

Marital status / Status perkahwinan Single Gender/Corporate / Jantina/Korporat Female

Head Office Postal Address Customer Contact Centre Website

Menara Shell, No. 211, Peti Surat 11228, 1 800 88 6333 www.kurnia.com
Jalan Tun Sambanthan, GPO Kuala Lumpur,
50470, Kuala Lumpur. 50740 W.P. Kuala Lumpur.
 Service Tax Registration No : B16-1808-31015443

MENG CHONG MOTOR Agency Code : 529900-00

AmGeneral Insurance Berhad (44191-P) NO.1, JALAN BUNGA ROS, TAMAN SRI KULAI BARU,
A member of the AmBank Group 81000 KULAI 07-6633345 ,013-
JOHOR DARUL TAKZIM

DETAILS OF VEHICLE / BUTIR-BUTIR KENDERAAN

Make and type of vehicle / Buatan dan jenis kenderaan TOYOTA VIOS G & 4D SEDAN

Use of vehicle / Penggunaan kenderaan NOT APPLICABLE TO ABOVE USAGE

Additional usage / Penggunaan tambahan Not Applicable

Reg. no. / Trailer no. / No. pendaftaran/No. VFM1311 / - Year of manufacturing / Tahun 2020
Vehicle for business use / Kenderaan untuk penggunaan perniagaan Yes / Ya X No / Tidak

Engine no. / No. enjin 2NR0P06851 Chassis no. / No. chassis PN153SYF103086623

Seating capacity / Muatan tempat duduk 5 CC / KG / Horse power / CC/KG/Kuasa kuda 1496.00 CC

Vehicle sum insured / Jumlah kenderaan diinsuranskan (RM) 71,000.00

Basis of coverage / Jenis perlindungan X Agreed Value / Nilai Dipersetujui Market Value / Nilai Pasaran

Trailer sum insured / Jumlah treler diinsuranskan (RM) 0.00

Vehicle purchase date / Tarikh pembelian kenderaan -

Vehicle purchase price / Harga pembelian kenderaan (RM) 0.00

Optional cover / Perlindungan opsyenal Windscreen Damage (Tempered/Laminated Glass Inclusive Labour Cost)(RM 1,500.00)

Named driver / rider / Pemandu yang dinamakan/penunggang ANY AUTHORISED DRIVER

Hire purchase owner / Pemilik sewa beli MAYBANK BERHAD

Is your vehicle normally kept at your corresponding / mailing address? / Adakah kenderaan anda biasanya disimpan di alamat kediaman
/ surat-menyurat anda?
Yes / Ya X No, Please specify vehicle kept address / Tidak, sila nyatakan alamat penyimpanan kenderaan anda

Garaged / Garaj PARKING LOT - COVERED Safety code / Kod keselamatan ABS & AIRBAGS (MORE THAN 2)

No. of claims (for the past 3 years) / Daily driving hours /

No. tuntutan (untuk 3 tahun lepas) Jam memandu harian

DETAILS OF NO CLAIM DISCOUNT (NCD) / BUTIR-BUTIR DISKAUN TANPA TUNTUTAN (NCD)

Name of previous insurer / Nama syarikat insurans terdahulu

Reg. no. / No. pendaftaran VFM1311 Policy no. / No. polisi -

NCD % / RM 25.0 as at / pada 10/8/21 12:00 AM

PREMIUM AND COVERAGE / PREMIUM DAN PERLINDUNGAN

Type of Cover / Jenis Perlindungan: COMPREHENSIVE PREMIER

Period of Insurance / Tempoh Insurance / From / Dari 00:00:01 AM 08-10-2021

Total Premium Due (inclusive of Service Tax and Stamp Duty) /

Jumlah Premium Dikehendaki (termasuk Cukai Perkhidmatan dan Duti Setem) (RM) 1,769.29
 Service Tax Registration No : B16-1808-31015443

MENG CHONG MOTOR Agency Code : 529900-00

AmGeneral Insurance Berhad (44191-P) NO.1, JALAN BUNGA ROS, TAMAN SRI KULAI BARU,
A member of the AmBank Group 81000 KULAI 07-6633345 ,013-
JOHOR DARUL TAKZIM

DECLARATION OF PROPOSER / PENGAKUAN PENCADANG

I/We hereby confirm that I/We have taken reasonable care to answer all the questions herein honestly and to the best of My/Our
knowledge, belief and recollection and that I/We shall remain under a continuous duty to inform the Company of any change,
amendment or addition to the aforesaid questions until the Policy is issued and comes into effect. I/We understand that the Company
may void the policy and reject any claim payable thereunder (whether in whole or in part) in the event of a deliberate
misrepresentation, misdescription, error, omission or non-disclosure of fact (whether or not there was an inquiry/question raised
pertaining to the same) with or without an intention to defraud the Company by Me/Us which would have affected the premium payable
or the acceptance of the risk by the Company. / Saya/Kami mengesahkan bahawa Saya/Kami telah memberi sepenuh perhatian untuk
menjawab kesemua soalan yang terkandung secara jujur di sepanjang pengetahuan, kepercayaan dan ingatan. Saya/Kami akan
bertanggungjawab untuk memberitahu pihak Syarikat sebarang perubahan, pindaan atau penambahan pada soalan di atas sehingga
Polisi dikeluarkan dan berkuatkuasa. Saya/Kami faham bahawa Syarikat boleh membatalkan Polisi ini dan menolak sebarang tuntutan
(sama ada keseluruhan atau sebahagian) sekiranya berlaku salah nyata, penerangan yang salah, kesilapan, tertinggal atau tidak
mendedahkan fakta (sama ada terdapat pertanyaan/persoalan ataupun tidak dikemukakan mengenai yang sama) dengan niat atau
tanpa niat untuk menipu Syarikat oleh Saya/Kami yang akan menjejaskan premium yang perlu dibayar atau terhadap penerimaan
risiko oleh pihak Syarikat.

Yes / Ya No / Tidak
I/We agree that the Company shall have the right to use My/Our data and personal information for the purpose of the insurance
operational process which might include transfer of data and personal information to the Company’s related companies, subsidiaries
and/or its holding company, outsourcing partners, reinsurers and solicitor but not limited to affiliate companies including their
outsourcing partners. / Saya/Kami bersetuju bahawa pihak Syarikat berhak untuk menggunakan data dan maklumat peribadi
Saya/Kami bagi tujuan pemprosesan operasi insurans yang mungkin termasuk pemindahan data dan maklumat peribadi kepada
Syarikat yang sekutu dengan pihak Syarikat, anak-anak syarikat dan/atau syarikat induknya, semua rakan kongsi pembekalan luar,
penanggung insurans semula dan peguam cara tetapi tidak terhad kepada syarikat-syarikat sekutu termasuk rakan kongsi pembekalan
luar mereka.

Yes / Ya No / Tidak
I/We further agree that the Company, its partners and its related companies, subsidiaries and/or its holding company can share and
use My/Our data and personal information for the purpose of promoting the Company’s and its related companies’, subsidiaries’ and/or
its holding company’s products, new services and support requirements; and marketing campaigns and activities and commercial
transactions. / Saya/Kami seterusnya bersetuju bahawa pihak Syarikat, rakan niaganya dan syarikat-syarikat sekutu, anak-anak
syarikat dan/atau syarikat induk berhak untuk berkongsi dan menggunakan data dan maklumat peribadi untuk tujuan mempromosikan
produk, perkhidmatan baru dan keperluan sokongan; dan kempen dan aktiviti pemasaran dan transaksi komersil yang dikendalikan
oleh pihak Syarikat dan syarikat sekutu, anak-anak syarikat dan/atau syarikat induk.

Yes / Ya No / Tidak
Signature of proposer /
Company’s chop /
Date /
Tandatangan pencadang /
Tarikh
Chop syarikat

ANTI-MONEY LAUNDERING, ANTI-TERRORISM FINANCING AND PROCEEDS OF UNLAWFUL ACTIVITIES ACT 2001 /
AKTA PENCEGAHAN PENGUBAHAN WANG HARAM, PENCEGAHAN PEMBIAYAAN KEGANASAN DAN HASIL DARIPADA AKTIVITI
HARAM 2001

For Agent / Staff Use Only / Untuk Ejen / Kakitangan Sahaja

In Compliance with Section 16(2) of the Anti-Money Laundering, Anti-Terrorism Financing and Proceeds of Unlawful Activities
Act 2001, I hereby certify that the Proposer’s original NRIC / Business Registration Certificate / Passport was verified and
authenticated by me at the Point of Sale. / Menurut Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram, Pencegahan
Pembiayaan Keganasan dan Hasil daripada Aktiviti Haram 2001, saya dengan ini mengesahkan bahawa Kad Pengenalan (KP)
/ Sijil Pendaftaran / Pasport asal Pencadang telah disahkan ketulenannya ketika urusniaga dijalankan.

Name of Proposer / Nama Pencadang

Cover Note / Policy No. / No. Sijil Insurans / Polisi

VERIFICATION / PENGESAHAN
Name of agent / staff / Nama ejen / kakitangan

NRIC no. / No. KP Date / Tarikh Signature / Tandatangan