UW-PW-S009 (MT)

REV: H
RTD Code: 08
PRIVATE CAR EX GOODS
M.X.1

"Please call KAA Toll Free 1-800-88-3833 for breakdown or accident assistance"
PRIVATE CAR SCHEDULE / JADUAL KERETA PERSENDIRIAN
The Insured / Pemegang Polisi Policy No. / No. Polisi
KHAIRULIZAM BIN ABDUL GHAFAR EVC3026598 01-01
Account No. / No. Akaun
NO. 5, JALAN MJ 1/7 891100-00
TMN. MERANTI JAYA
SELANGOR Type of Cover / Jenis Perlindungan
47100 PUCHONG COMPREHENSIVE
Period of Insurance / Tempoh Insurans
From/Dari 00:00:01AM 02-03-2010 to/hingga 01-03-2011
Occupation / Pekerjaan DOCTOR Bus. Regn. No / Premium / Premium 2,358.20
I.C. No. / No. Kad 730822145597 No. Pendaftaran Perniagaan
Pengenalan A2343214 All Rider / Semua Penunggang 0.00
Vehicle Age Loading / Tambahan Untuk
Hire Purchase Owner / Pemilik Sewa Beli Usia Kenderaan 0.00% 0.00
MAYBANK BERHAD Insured's Age Loading / Tambahan
Make & Type of Body / Buatan & Jenis Badan Untuk Usia Pemegang Polisi 0.00% 0.00
Registration No. / Claim Experience Loading / Tambahan
No. Pendaftaran TOYOTA ESTIMA / VAN
Untuk Pengalaman Tuntutan 0.00% 0.00
WPW8448 Excess / Lebihan Regn. Card No. / No. Kad Maximum Cumulative Loading /
0.00 Pendaftaran Tambahan Berganda Maksima 0.00% 0.00
4838150 2,358.20
NCD / Diskaun Tanpa Tuntutan 55.00%
Carrying or Seating Capacity Tonnage / C.C. / Estimate of Value incl. Wef / Berkuatkuasa dari 02-03-2010 1,297.01
Incl. Driver / Muatan Tan / Keupayaan Enjin Accesories and Spare Parts 1,061.19
Tempat Duduk termasuk 2362.00 CC / Nilai Anggaran termasuk
Pemandu Year of Manufacture / aksesori dan alat-alat ganti Gross Premium / Premium Kasar 1,061.19
8 Tahun Diperbuat Service Tax / Cukai Perkhidmatan 0% 0.00
2001 80,000.00 Stamp Duty / Duti Setem 10.00
Engine No. / No. Enjin
2AZ0477386 Act / Akta 38.47
Chassis no. / No. Casis Trailer / Treler
ACR30-0122678 -

Only The Extensions, Endorsement & /Or Warranties Indicated Below Apply To This
Policy. / Hanya Lanjutan, Endorsemen dan/atau Warranti sepertimana yang dinyatakan di
bawah ini boleh diguna pakai dalam polisi ini.
2,2(f),30,100,106,WARRANTY NO.1,15

Total Due / Jumlah Berbayar 1,071.19

Subject to IMPORTANT NOTICE: Your duty as the Owner of the vehicle as attached. Total Due (OTC) / Jumlah Berbayar 1,071.20
Di Kaunter

Authorised Driver / Pemandu yang Diberi Kuasa:

THE POLICYHOLDER, MASLILAWATI BINTI MANSOR
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 KURNIA INSURANS (MALAYSIA)
Gantian No. Nota AHMAD FUAD MAHMOOD BERHAD
Perlindungan ENTERPRISE
Renewal of Policy No. / AHMAD FUAD MAHMOOD
Pembaharuan No. Polisi ENTERPRISE
Date of Proposal or 24-02-2010 NO 3C JALAN KENARI 2
Declaration / Tarikh BANDAR PUCHONG JAYA
Cadangan atau 47100 PUCHONG
Pengisytiharan SELANGOR
Tel : 03-58916227
Fax : 03-58916227
_________________________________________________
Authorised Signature / Tandatangan Yang Diberi Kuasa

Date of Issue / Time 24-02-2010 / 12:45:57PM

Tarikh Dikeluarkan / Waktu
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.
e-ASC 9*802*-1084*2430*1*9-1-2

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 Policy Document No./ UW-PW-S009 (MT)
No.Dokumen Polisi: REV: H
C.I.Code /
Kod Sijil Insurans: M.X.1

CERTIFICATE OF INSURANCE / SIJIL INSURANS

AKTA PENGANGKUTAN JALAN RAYA 1987 (MALAYSIA) RTD Code: 08
ORIGINAL COPY /
PERATURAN KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA) 1959 (MALAYSIA)
SALINAN ASAL AKTA KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA DAN PAMPASAN) (KAP 189) REPUBLIK SINGAPURA
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

EVC3026598 01-01 Excess : 0.00 Sum Insured : 80,000.00
1. Index Mark and Registration Number of Vehicle / Tanda Indeks dan No. Pendaftaran Kenderaan
WPW8448 NCD : 55.00% Wef : 02-03-2010

2. Name of Policyholder / Nama Pemegang Polisi

KHAIRULIZAM BIN ABDUL GHAFAR
3. Period of Insurance / Tarikh Insurans
From / Dari 00:00:01AM 02-03-2010 to / hingga 01-03-2011
4. Persons or Classes of Persons entitled to drive / Orang atau kelas orang yang layak 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 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 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.
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.
x
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 & 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
(1) Report to the Police within 24 hours upon accident.
(2) Notify us in writting with full details as soon as possible after an event which may become the subject of a claim for / untuk KURNIA INSURANS (MALAYSIA) BERHAD
under this Policy. (Incorporated in Malaysia / Ditubuhkan di Malaysia)
(3) No repairs may be authorized to Your Vehicle without Our prior written consent. Approved Insurers / Penanggung Insurans Yang Dibenarkan
(4) Private Car Own Damage Claim - In the event of claim, repairs must be conducted by Authorized Panel
Workshop selected and approved by Us. Failure to remove Your Vehicle to an approved workshop would be a
breach of Endorsement 106 and We shall have the right to decline liablility under Section A of this Policy.
(5) Accident Involving Third Party - If You are involved in an accident causing injury to any person or damage to
any property or other vehicle You must:
(a) try to exchange Insurance particulars with owners of vehicles involved.
(b) try to obtain the name & address of any witness to the accident.
(c) report to the Company immediately.
(d) refer to the Company immediately all communications received and immediately send all letters received to
the Company unanswered.
(e) not pay any money to any party involved in the accident without the Company's written permission.
(6) Duty of Disclosure - If You fail to disclose to Us fully and faithfully, all the facts which You know or ought to ___________________________________________
know, or if You misrepresented any facts to Us before the Policy was entered into, We may avoid this Policy. Authorised Signature / Tandatangan Yang Diberi Kuasa
You must observe and fullfill the Terms, Conditions, Endorsements, Clauses or Warranties of the Policy.
(7) The Insured shall take all reasonable steps to safeguard the Motor Vehicle from loss or damage.
(8) We shall have full discretion in the conduct, defence and/or settlement of any claim.
N.B. We reserve the right to cancel this Policy by giving 14 days written notice by registered post to Your last known Agent Code / Kod Ejen: 891100-00
address.
e-ASC 9*802*-1084*2430*1*9-1-2

Important Notice: For environmental conservation, we no longer print the policy wordings. You may view the policy document number at www.kurnia.com. Print out can be obtained from our branch
offices located nationwide or from your servicing agents.
Kenyataan Penting: Untuk pemeliharaan alam sekitar, kami tidak lagi mencetak butir-butir polisi. Anda boleh membaca butir-butir polisi untuk dokumen polisi bernombor diatas di www.kurnia.com.
Cetakan polisi boleh diperolehi daripada pejabat cawangan Kami di seluruh negara ataupun daripada ejen Kurnia Anda.

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 EVC3026598
Statement Pursuant to Section 149(4) of the Insurance Act, 1996- You are to disclose in this Kenyataan Mengikut Seksyen 149(4) Undang-undang Insurans 1996- Kamu adalah diminta
proposal form, fully and faithfully all the facts which you know or ought to know otherwise the policy menerangkan dengan penuh dan benar segala butir-butir yang kamu tahu atau harus tahu di atas
may be invalidated. cadangan insurans ini, jika tidak polisi yang dikeluarkan menurut cadangan ini adalah tidak sah.
Note:It is hereby understood and agreed that if the motor vehicle shall at all time of happening of any loss or damage (be it partial/total) be insured for a sum less than its market value then, the insured
shall be considered as being his own insurer for the difference and shall bear the rateable proportion of the loss accordingly. Provided always that this clause shall not apply unless the market value at the
time of loss exceeds the insured value by 10%. The market value of a vehicle would be determined in accordance to Endorsement 99 on "Indemnity In The Event of Total Loss Clause"
RTD CODE: 08

DPPA / MCPA / MOTOR PROPOSAL FORM

Road Transport Act. 1987 (Malaysia)
Motor Vehicles (Third Party Risks) Rules 1959 (Malaysia)
Motor Vehicles (Third Party Risks and Compensation) Act (Cap 189) Republic of Singapore
Motor Vehicles (Third Party Risks and Compensation) Rules 1960 (Republic of Singapore)
Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) negara Brunei Darussalam

IMPORTANT NOTICE: This Cover Note will not be valid if issued after
Agent Account Code 891100-00 Date / Time Issued 24-02-2010 00:00:01AM AM/PM

Agency AHMAD FUAD MAHMOOD ENTERPRISE

Insured Name KHAIRULIZAM BIN ABDUL GHAFAR

Address 1. NO. 5, JALAN MJ 1/7

2. TMN. MERANTI JAYA
3. SELANGOR
4.

Geographical location: (State where your vehicle will usually be garaged overnight) Within Compound of Residence

NRIC & OLD / Business Regn. No. 730822145597 Occupation / Trade DOCTOR

Tel. No (Hse) - (Off.) - Hand Phone 0192236363- E-mail -

Marital Status Single[] / Married[] / Others[X] Gender / Body Corporate Company[] / Male[X] / Female []

I/We propose for insurance and agree to pay RM 1,071.19 as premium in respect of the Motor Vehicle described in the Schedule below. The acceptance of risk is subject to the Company's standard
COMP / TP / TPFT Policy terms applicable for the period from 00:00:01AM on 02-03-2010 to midnight on 01-03-2011 . I/We hereby also propose for Personal Accident insurance as indicated
in the Schedule below in respect of the said Motor Vehicle ( If so indicated by X)

SCHEDULE
Make & Type of Vehicle TOYOTA ESTIMA Reg. No / Trailer No. WPW8448 / -

Engine No. 2AZ0477386 Year Of Make 2001

Chassis No. ACR30-0122678 Seating Capacity 8

CC / KG / Horse Power 2362.00 CC Sum Insured (RM) 80,000.00

Use of Vehicle [PVT / COMM] NOT APPLICABLE TO ABOVE USAGE Trailer Sum Insured (RM) 0.00

Vehicle Purchase Date - Vehicle Purchase Price (RM) -

Loading % / RM 0.00 / 0.00 CFY % / RM 55.00 / 1,297.01 As At 02-03-2010

Excess is minimum 2.5% of Sum Insured unless otherwise stated herein. Excess (RM) 0.00

Extra Benefits -

Authorised Driver / Rider THE POLICYHOLDER, MASLILAWATI BINTI MANSOR -

Hire Purchase Owner MAYBAN MAYBANK BERHAD Renewal [] / Extension[] / Transfer [] / New.[X]

Passengers Liability is excluded from the cover under this Policy unless otherwise stated. 5% Service Tax (RM) 0.00
-

Age of proposer: 36 Date of Birth: 22-08-1973 Occupation or Business: DOCTOR

DPPA [ ] MCPA [ ] (Please X) Driving License first issued Full [ ] Provisional "L" [ ]

Please X against appropriate column

PRIVATE CAR COMMERCIAL VEHICLES MOTORCYCLE TAXI BUSES
[ ] Private Social & Domestic [ ] "A" Permit [ ] Single Riders [ ] Town [ ] Airport Limousine [ ] School
Purposes Only
[ ] Including Company Purposes [ ] "C" Permit [ ] All Riders [ ] Intertown [ ] Factory ( Hire & Reward)
[ ] Special Type (Please Specify) [ ] Private Use [ ] Hire Car (Chauffeur Driven) [ ] Factory (Carriage of own Workers)
[ ] Commercial Use
...................................
[ ] Others (Please Specify) [ ] Others (Please Specify) [ ] Others (Please Specify) [ ] Others (Please Specify) [ ] Others (Please Specify)

................................... ................................... ................................... ................................... ...................................

Please provide copy of permit granted by Is Excursion Trip cover required?
JPJ [ ] YES [ ] NO

[ ] DRIVERS AND PASSENGERS PERSONAL ACCIDENT INSURANCE (DPPA) [ ] MOTOR CYCLIST PERSONAL ACCIDENT INSURANCE (MCPA)

(Applicable only to Private Car, Private Van, Goods Carrying Vehicle, Town Taxi, Outstation Taxi, Factory Van and Motorcycle )

Plan: - Sum Insured (RM) - Premium (RM) -

Note: Please refer to DPPA/MCPA brochures for premium table. No MC.

Important Notice: For environmental conservation, we no longer print the policy wordings. You may view the policy document number at www.kurnia.com. Print out can be obtained from our branch
offices located nationwide or from your servicing agents.
Kenyataan Penting: Untuk pemeliharaan alam sekitar, kami tidak lagi mencetak butir-butir polisi. Anda boleh membaca butir-butir polisi untuk dokumen polisi bernombor diatas di www.kurnia.com.
Cetakan polisi boleh diperolehi daripada pejabat cawangan Kami di seluruh negara ataupun daripada ejen Kurnia Anda.

Page 3
1. State whether to the best of your knowledge and belief, you or any other person who will drive:

(a) suffer from defective vision or hearing or from any physical or mental infirmity: (a)Yes [ ] No [ ]
If so, state particulars. ...................................................................
(b) have been convicted of any offence in connection with the driving of any motor vehicle. (b)Yes [ ] No [ ]
If so, state date and nature of penalty. ...................................................................

(c) ever met with any accident during the past three years. (c)Yes [ ] No [ ]
...................................................................

(d) ever made a Claim during the past three years under any Motor Policy. (d)Yes [ ] No [ ]
If so, please give full particulars. ...................................................................

2. Are you entitled to a "No Claim Discount" from your previous Insurer? If yes, please attach previous Policy Name of Insurer(s) ............................................................
Schedule or Renewal Notice or Endorsement pertaining to NCD Entitlement and letter of undertaking. If the
NCD is obtained falsely, the policy is null and void." Policy No. ............................................................

Vehicle Reg No. ............................................................

Anti Theft Device Safety Features Geographical Location / Garaged

Factory Fitted Alarm Airbags Installed YES NO Roadside - Public Parking 01

Immobilizer No. of Airbags Outside Residence Compound 02

GPS ABS Braking System Installed Within Residence Compound 03

Steering or Gear Lock YES Parking Lot (Open) 11

Tracking System NO Parking Lot (Covered) 12

Others 99

KENYATAAN PENTING IMPORTANT NOTICE

Perhatian tuan adalah diarah kepada Seksyen 141 Akta Insurans 1996: Your attention is drawn to Section 141 of the Insurance Act 1996:
Perlindungan insurans tidak akan diberi sehingga premium dibayar mengikut peraturan-peraturan No cover can be granted until premium has been paid in accordance with the Regulations issued
yang dikeluarkan di bawah seksyen ini. Sesiapa yang gagal mematuhi peraturan ini adalah under the Section. Any person who fails to comply with this Section shall be guilty of an offence
melakukan suatu kesalahan dan jika bersabit kesalahannya boleh didenda tidak lebih daripada and shall on conviction be liable to a fine not exceeding RM500,000/-. Where payment of the
RM500,000/- Sekiranya bayaran dibuat melalui cek semasa, kiriman wang, wang pos, bank draf premium is made by cheque, money order, postal order, bank draft or cashier's order, the payment
atau cek juruwang, bayaran hendaklah berpalang "Akaun Penerima Sahaja" kepada Kurnia must be made in favour of Kurnia Insurans (M) Berhad and crossed. "Account Payee Only"
Insurans (M) Berhad.

PEMBERITAHUAN KHAS DI DALAM BORANG-BORANG CADANGAN SPECIAL NOTIFICATION IN PROPOSAL FORMS

Pencadang dengan ini diberitahu bahawa Syarikat ini telah melantik ejen-ejen/ wakil-wakil yang The proposer is hereby notified that the company has appointed agents/representatives who have
mempunyai kuasa mengurusniaga atau menguruskan kontrak-kontrak Insurans bagi pihak Syarikat the authority to solicit or negotiate contracts of insurance on behalf of the company. All authorised
ini. Semua ejen-ejen/wakil-wakil yang diberi kuasa adalah dibekalkan dengan kad-kad Kuasa. agents/representatives are with authorisation cards.

DECLARATION BY PROPOSER
I/We to the best of knowledge hereby confirm that the statements contained in this proposal form are true and correct and I/We have not concealed, misrepresented or mis-stated any material fact.
I/We agree that the statements and declaration contained in this proposal form shall be basis of the contract of insurance with the company and are deemed to be incorporated in the contract.

IC No:..........................................................

Date: ........................................................... ...................................................

Signature of Proposer
In Compliance with Section 16(2) of the Anti-Money Laundering Act 2001
I hereby certify that the Proposer's original NRIC/Business Registration Certificate was verified and authenticated by me at the point of sales.

Third Party verification:-

Signature : _______________________________________ NRIC : _______________________________________

Name : _______________________________________ Date : _______________________________________
"Third Party" means by insurance agents, insurance brokers or staff of insurance companies
[ ] To maintain a copy of NRIC for applicants for individual insurance policies with aggregate annual premium exceeding RM50,000.00
[ ] To maintain a copy of Business Registration Certificate for companies with aggregate annual premium exceeding RM100,000.00

BRANCHES:
Alor Setar:Tel: 04-7339888 Fax: 04-7305888 .Batu Pahat:Tel: 07-4326333 Fax: 07-4323522 . Butterworth:Tel: 04-39793888 Fax: 07-3978279 . Ipoh:Tel: 05-2552846 Fax: 05-2413937 .Johor Bahru:
Tel: 07-2383328 Fax: 07-2383731 . Kangar:Tel: 04-9764226 Fax: 04-9768914 . Klang: Tel: 03-33428333 Fax: 03-33449775 .Kluang:Tel: 07-7738000 Fax: 07-7722558 . Kota Bharu:Tel: 09-7481033
Fax: 09-7449633 . Kota Kinabalu: Tel: 088-232200 Fax: 088-232204 .Kuala Lumpur:Tel: 03-26989333 Fax: 03-26989933 .Kuala Terengganu: Tel: 09-6246561 Fax: 09-6246531. Kuantan:Tel: 09-
5664527 Fax: 09-5661164.Kuching: Tel: 082-247288 Fax: 082-250611 .Melaka: Tel: 06-2830928 Fax: 06-2822707 . Miri: Tel: 085-420102 Fax: 085-420924 .Penang: Tel: 04-2284473 Fax: 04-2284478.
Segamat: Tel: 07-9321299 Fax: 07-9328551 . Selangor: Tel: 03-21481500 Fax: 03-21421446 .Seremban: Tel: 06-7670333 Fax: 06-7672487 .Sibu: Tel: 084-348333 Fax: 084-317766 . Sitiawan: Tel:
05-6919333 Fax: 05-6911333 . Sungai Petani: Tel: 04-4428333 Fax: 04-4428212 . Taiping:Tel: 05-8086333 Fax: 05-8083223 . Tawau: Tel: 089-762633 Fax: 089-762533 . Temerloh:Tel: 09-2960933
Fax: 09-2966933

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 UW-MT-F101
REV: E

LETTER OF UNDERTAKING

To : KURNIA INSURANS (MALAYSIA) BERHAD (44191-P)

(A member of the Kurnia Group of Companies)
HEAD OFFICE : Menara Kurnia, No.9, Jalan PJS 8/9, 46150 Petaling Jaya, P.O. Box 8607, 46792 Petaling Jaya, Selangor Darul
Ehsan.
Tel: 603-7875 3333 Fax: 603-7875 9933 E-mail: [email protected] Website: www.kurnia.com
From : KHAIRULIZAM BIN ABDUL GHAFAR
NO. 5, JALAN MJ 1/7
TMN. MERANTI JAYA
SELANGOR
47100 PUCHONG
Date : 24-02-2010

Dear Sir,

NCD Entitlement : 55.00 %

Vehicle No : WPW8448

I/C No.(Old/New) : 730822145597/A2343214

I am currently holding a valid *COMPREHENSIVE Motor Policy with AXA AFFIN GENERAL INSURANCE BERHAD
I intend to transfer or claim my 55.00 % NCD entitlement to a Vehicle No. WPW8448 to be insured with You or purchase a policy
from Your Company (See Note No.1)
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.

__________________________
Insured Signature

Note:

NCD from Overseas

Duly Signed Letter of Undertaking and the original NCD confirmation letter stating the number of claims free years must be submitted

* delete whichever is not appropriate

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