PRO Public Liability
PRO Public Liability
PRO Public Liability
Allianz General
General Insurance
Insurance Company
Company (Malaysia) Berhad
Berhad (735426-V)
(Malaysia) PROPOSAL
(735426-V)
FORM
Allianz General Insurance Company (Malaysia) Berhad (735426-V)
PUBLIC
PUBLIC LIABILITY
LIABILITY INSURANCE
INSURANCE
IMPORTANT
PUBLIC LIABILITY
PROPOSAL INSURANCE
FORM
PROPOSAL FORM
STATEMENT PURSUANT TO SECTION 149(4) OF THE INSURANCE ACT 1996 - You are to disclose in this proposal form, fully and faithfully
all the facts which you know or ought to know, otherwise the policy issued hereunder may be invalidated.
Account No:
PROPOSAL FORM
Allianz
IMPORTANT
Allianz General
NOTICEInsurance
General Insurance
TO PROSPECTIVE
Company
POLICY(Malaysia)
Company OWNERS
(Malaysia)
Berhad (735426-V) Berhad
is licensed(735426-V)
under the Financial Services Act 2013 (FSA) and
Policy owners are advised to read the policy carefully and understand the contents therein. You are encouraged to seek clarification from the
Policy No:
regulated by Bank Negara Malaysia (BNM).
insurer if necessary.
IMPORTANT Account No:
NON-CONSUMER
IMPORTANT
STATEMENT PURSUANTINSURANCE CONTRACT
TO SECTION 149(4) OF THE INSURANCE ACT 1996 - You are to disclose in this proposal form, fully and faithfully Account No: No:
Cover Note
STATEMENT PURSUANT TO SECTION 149(4) OF THE INSURANCE ACT 1996 - You are to disclose in this proposal form, fully and faith
mpany or offor f u l ly
ficiapurposes
IMPORTANT
Tthe
he lfacts
Pursuant
all iabilto itwhich
y Paragraph
of thyou
e Coknow
mp4anof
yordSchedule
oought
es nottocoknow,
9mof
methe
notherwise
ce Financial
until acthe
cepServices
tance oissued
policy f thAct
e phereunder
roposalifhayou
2013, s beare
may ebe
n iinvalidated.
n timated bfor
applying y ththis
e CoInsurance l related Account No:
all
to the facts
cover
yournote
STATEMENT
IMPORTANT
all the factsthe
accepting
IMPORTANT
which
issued.
trade,
PURSUANT
NOTICE
which
you know
business
risks
NOTICE
or ought
TO SECTION
TO PROSPECTIVE
you
TO know
and or ought
determining
PROSPECTIVE
to know,
or profession,
149(4)
POLICY
to the
POLICY
otherwise
OF THE
you
OWNERS
know,
havethe
INSURANCE
otherwise
rates
OWNERS and
PUBLIC LIABILITY INSURANCE
policy
the policy
terms to
toissued
ACT 1996
a duty
be issued
applied
hereunder
- You
disclose areany
hereunder
and any
may beininvalidated.
to disclose
matter
may
this you
that proposal
be invalidated.
matter a
know
reasonable
form,
to fully
person
and faithfuto
be relevant
in the
lly our decision in
circumstances
Policy No:
could Policy No:
be expected
Policy ownersNOTICE
IMPORTANT
insurer if necessary. to
are know
advised
TO to
tobe relevant,
read
PROSPECTIVEthe policyotherwise
POLICYcarefully
OWNERSandit may result
understand in
the avoidance PROPOSAL
of
contents therein. contract, claim
You are encouragedFORM
Policy owners are advised to read the policy carefully and understand the contents therein. You are encouraged to seek clarification from the
denied
ALL QUESTIONS MUST BE ANSWERED BY THE PROPOSER AND APPROPRIATELY MARKED ' ' WHERE APPLICABLE. or
to seek reduced,
clarificationterms
from thechanged or varied, Policy No:
or contract
insurer
Policy terminated.
if necessary.
owners are advised to read the policy carefully and understand the contents therein. You are encouraged to seek clarification from the Cover Note No:
This
The duty
insurer ilitof
y odisclosure
liifabnecessary.f the Companshall
y doescontinue
not communtilence uthe
ntil atime
cceptathe contract
f the propis osaentered
l has beeninto,
intimvaried
ated by or
therenewed. Cover Note No:
The liability of the Company does not commence until acceptance of the proposal COMPANY has been intimateDATA
nce o Company or official
cover note issued. d by the Company or official
cover note issued.
Cover Note No:
TheThe liability
liability of
of the
the CCompany
ompany dodoes
es nonot
t com mence untiluntil
commence accepacceptance
tance of the of
prothe
posaproposal
l has beenform
intimhas
atedbeen
by thintimated
e Companyby
or the
officCompany
ial
Name
IMPORTANT of Proposer
cover note issued. Account No:
or(inofficial
STATEMENT cover note
PURSUANT
block letters and isper
asTO issued.
SECTION
NRIC / 149(4) OF THE INSURANCE ACT 1996 - You are to disclose in this proposal form, fully and faithfully
allPassport)
the facts which you know or ought to know, otherwise the policy issued hereunder may be invalidated.
ALL QUESTIONS MUST BE ANSWERED BY THE PROPOSER AND APPROPRIATELY MARKED ' ' WHERE APPLICABLE.
IMPORTANT ALL QUESTIONS
ALL
NOTICE TO PROSPECTIVE QUESTIONS
POLICY OWNERS MUST BE
MUST BE ANSWERED
ANSWERED BY BY THE
THE PROPOSER
PROPOSER AND AND APPROPRIATELY
APPROPRIATELYMARKED
''WHERE MARKED''
WHEREAPPLICABLE.
APPLICABLE.
Policy No:
Company No.
COMPANY
Policy owners are advised to read the policy carefully and understand the contents therein. DATA
You are encouraged
COMPANY
to seek clarification from the
insurer if necessary.
Name COMPANY DATA DATA
Postal of
Name of
Proposer
Address
Proposer Cover Note No:
(in
Theblock
Name billetters)
liaof Proposer
ity of the Company does not commence until acceptance of the proposal has been intimated by the Company or official
(in block letters)
cover note issued.
(in block letters and as per NRIC /
Postcode State
Passport) No.
Company
Company No.
Tel. No.
Company
Goods andNo. Services Tax (GST)
Postal Address ALL QUESTIONS MUST BE ANSWERED BY THE PROPOSER AND APPROPRIATELY MARKED ' ' WHERE APPLICABLE.
Related
Postal
Business, Questions
AddressTrade or
Postal Address
Are You registered
Occupation for GST?
of Proposer Yes No COMPANY DATA
Postcode
IfName
Yes, please provide: i) GST Registration State
Date: ii) GST Registration No:
Postcode of Proposer State
I(in
f you
Postcode
Tel. areletters)
block
No. a Business Entity, are You StateDay Month Year
O Yes No HP
aTel. No.
Sole Proprietor? O HP
Tel.
IfEmail No.
yes, is the subject matter insured
Period
Email of Insurance From Business Non Business Both To
Company
for No.
Business, Trade Trade or
or Day Month Year Day Month Year
Business,
Business,
Occupation Trade
of or
Proposer
Occupation
Situation
Postal Address of Proposer
of Premises
Occupation of Proposer
to which this
Insurance applies
Postcode From State To
Period of Insurance From To
Period of Insurance Day Month Year Day Month Year
Plant
Tel. or Insurance
No.of
Period Machinery used From Day Month Year To Day Month Year
O HP
Situation
in connection of Premises
with Day Month Year Day Month Year
Situation
Email of Premises
to which this
Proposer's Business
to which
Situation of this Premises
Insurance applies
Insurance
Business,
to whichTrade applies
this or
Plant or
Proposer's
Occupation
Insurance Machinery
Proposerused
Estimated:
ofapplies
Plant or Machinery used
in
1. connection
Turnover/orwith
in connection with 1. 2.
Proposer's
2. Wageroll Business
Plant or Machinery for
Proposer's Business used From To
Period of Insurance
in Period
connectionofEstimated:
Insurance
with
Proposer's Day Month Year Day Month Year
Proposer's
Proposer's Estimated:
Business
1. Turnover/or
1. Turnover/or
Situation
Particulars of ofPremises
Contract 1. 2.
2. Wageroll for 1. 2.
2. Wageroll
to which
which of this forproposal
thisInsurance
Period
Proposer's Estimated:
Period
Insurance of Insurance
applies
relates (if applicable)
1. Turnover/or
Particulars
Plant offor
or Machinery
2. Wageroll Contract used 1. 2.
Particulars of Contract
to connection
in which this proposalwith
to Period
which this of Insurance
proposal Any one accident RM ______________________________ Any one period of Insurance RM _____________________
relates (if applicable)
Proposer's Business
relates (if applicable)
Limits of Liability
Particulars Estimated:
Proposer's of Contract Excess
Any OneRM ____________________
Accident (third party property damage
RM ______________________________ Any Oneonly)
Period of Insurance RM _____________________
to Turnover/or
which this proposal Any One Accident RM ______________________________ Any One Period of Insurance RM _____________________
1.
Limit of(if
Liability
relates
Limit applicable)
of Liability Excess
1. RM ____________________ 2.
2. Wageroll for Excess RM ____________________
Period
BASIC of Insurance
COVERS
BASIC COVERS
BASIC COVERS Any one accident RM ______________________________ Any one period of Insurance RM _____________________
Particulars
The Company
Company of Contract
will indemnify
will indemnify the the Proposer Proposer in in respect
respect of of :-:-
The
to Company
Limits
which of will indemnify the Proposer in respect of :-
Liability
this proposal
(A) All sums sums whichwhich the the Proposer
ProposerExcess shall become
shall become legally liable
legally liable toto pay pay for for compensation
compensation
party propertyin in respect
respect of
of
(A)
relatesAll(if sums which the Proposer shall become legally liable to pay(third
applicable)
RM ____________________ for compensation in damage only)
respect of
(1) Accidental bodily
Accidental bodily injuryinjury to to anyany person
person
(1) Accidental bodily injury to any person
Accidental damage
(2) Accidental damage to to Third Third
Any One Party
Party property
property
Accident caused
RMcaused on or
on or about
about the
______________________________ the Premises
Premises in in connection
connection with the
with
Any One Period the Business of
Business of the
the Proposer
Proposer as as stated
stated above above
(2) Accidental damage to Third Party property caused on or about the Premises in connection withofthe Insurance
BusinessRM of _____________________
the Proposer as stated above
BASIC
(B) COVERS
All costs
costs
Limit ofAllLiability and
and expenses
expenses of
of litigation
litigation
Excess RM ____________________
(B) costs and expenses of litigation
(1) Recovered
Recovered byby any any claimant
claimant or
or claimants
claimants
The Company
(1) Recovered will indemnify
by any the Proposer
claimant or in respect of :-
claimants
(COVERS
2) IInnccuurrrreedd w
wiiitttthe
hh tthhee wwrrriiitttttteeen ccoonnsseenntt ooff tthhee CCoom
mp annyy iinn rreessppeecctt ooff aa ccllaaiim
m aaag ainst thee PPrrooppoosseerr ffoorr ccoommp ensation to w wh ich the Indem mn ity expressed
BASIC
(A) (All 2) sums
Incurrwhich
ed w h theProposer
w nn shall
consebecome
nt of thelegally Com ppaaliable
ny in to respaypectfor of acompensation
claim ggaaiinnssttintthherespect
Proposof
er for com ppeennssaattiioonn ttoo w hhiicchh tthhee IInnddeem nniittyy eexxpprreesssseedd
The Company in
in the
the Policy
Policy
willPolicy
indemnify applies
applies the Proposer in respect of :-
(1) in Accidental
the bodily
applies injury to any person
OTHERAll
(A) EXTENSIONS
sums whichREQUIREDthe Proposer shallParty
become legally liable on to or payaboutfor compensation
the Premises in in respect of with the Business of the Proposer as stated above
OTHER(2) Accidental
EXTENSIONS damage
REQUIRED to Third property caused connection
OTHER(1)
1. EXTENSIONS
Accidental REQUIRED
bodily injury to any person
1.
(B) All costs and expenses of litigation
2.
1. (2) Accidental damage to Third Party property caused on or about the Premises in connection with the Business of the Proposer as stated above
2. (1) Recovered by any claimant or claimants
3.
(B) All
3.
2. (2) costs
Incurandred expenses
with the wofritlitigation ten consent of the Company in respect of a claim against the Proposer for compensation to which the Indemnity expressed
(1) Recovered
in the Policy by applies
any claimant or claimants
3. (2) Incurred with the written consent of the Company in respect of a claim against the Proposer for compensation to which the Indemnity expressed
in the Policy applies
OTHER EXTENSIONS REQUIRED
OTHER
Head Office EXTENSIONS
: Suite 3A-15,REQUIRED
Level 15, Block 3A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel : 03-2264 1188 / 03-2264 0688 Fax : 03-2264 1199 www.allianz.com.my
1.
Customer Service : Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel: 03-2264 0700 Fax: 03-2264 0602 Toll Free : 1-300-88-1028 [email protected]
1.
Updated 09/09
AZ05/2015
2.
3.
3.
Head Office : Suite 3A-15, Level 15, Block 3A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel : 03-2264 1188 / 03-2264 0688 Fax : 03-2264 1199 www.allianz.com.my
HeadOffice
Head Office
Customer Suite :3A-15,
Service :: Ground Level 29,
Floor,LevelMenara
Block15,2A,
Block Allianz
3A,
Plaza Sentral,
Plaza
Sentral, Jalan 203,
Sentral,
Stesen Jalan
Jalan Tun5,
Stesen
Sentral Sambanthan,
Sentral
Kuala5,Lumpur Kuala
Kuala Lumpur Lumpur
Sentral, Sentral, Sentral, 50470
50470Lumpur.
50470 Kuala Kuala Kuala Lumpur.
Lumpur.
Tel: 03-2264 0700 Fax:Tel : 03-2264
03-2264 1188
0602 Toll/ Free
03-2264 0688 Fax : 03-2264
: 1-300-88-1028 1199 www.allianz.com.my
[email protected]
Customer
Service : GroundTel Floor,
: Block2264
+603 2A, Plaza
1188 Sentral,
/ 2264 Jalan
0688 Stesen
Fax: Sentral
+603 5, Kuala
2264 Lumpur
1199 Sentral, 50470 Kuala Lumpur.
www.allianz.com.my Tel:www.facebook.com/AllianzMalaysia
03-2264 0700 Fax: 03-2264 0602 Toll Free : 1-300-88-1028 [email protected]
Updated 09/09
Head Office : Suite 3A-15, Level 15, Block 3A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel : 03-2264 1188 / 03-2264 0688 Fax : 03-2264 1199 www.allianz.com.my
Updated 09/09
Customer Service : Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel: 03-2264 0700 Fax: 03-2264 0602 Toll Free : 1-300-88-1028 [email protected]
Customer Service : Allianz Arena, Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur.
Updated 09/09
Allianz Contact Center: 1 300 88 1028 Fax: +603 2264 8499 Email: [email protected]
1. Are the Plant and Machinery kept in sound and proper Yes No
condition or otherwise maintained in accordance with
Government requirement?
3. (a) Are there any boilers or pressure vessels used in (a) Yes No
the Premises?
(b) Are they insured against breakdown or (b) Yes No
explosion?
1. If
Are the Plantgive
so, please andfull particulars.
Machinery kept in sound and proper Yes No
condition or otherwise maintained in accordance with
4. Please state what
Government acids, gases, chemicals, explosives or
requirement?
other dangerous substances will be used and to what
extent?
2. Will work be undertaken elsewhere than on the
5. Premises?
Are you at Ifpresent
so, please stateagainst
insured territorial
anylimits.
of the risks you Yes No
Yes No
now wish to insure against? If so, please give full
particulars.
3. (a) Are there any boilers or pressure vessels used in (a) Yes No
6. Has anytheInsurance
Premises?Company ever
(b) declined
(a) Are they your
insured against breakdown or
proposal? (a)
(b) Yes No
explosion?
(b) refused to renew your policy? (b) Yes No
If so, please
(c) giveyour
cancelled full policy?
particulars. (c) Yes No
(d) required an increased rate or imposed special (d) Yes No
4. Pleaseterms
state on
what acids, gases, chemicals, explosives or
renewal?
other
If dangerous
so, please give substances will be used and to what
full particulars.
extent?
7. Have any claims been made upon you during the last
5. Are
two youyearatinpresent
respectinsured against
of injuries to any of the
persons orrisks
for you Yes
Yes No
No
now wish to insure against?
damage to property of third parties? If so, please give full
particulars.
If so, please give full particulars and state amounts Amount
Year Number
paid and unpaid. Paid Unpaid
6. Has any Insurance Company ever
(a) declined your proposal? (a) Yes No
(b) refused to renew your policy? (b) Yes No
(c) cancelled your policy? (c) Yes No
PREMIUM (d) WARRANTY
required an CLAUSE
increased rate or imposed special (d) Yes No
It is a fundamental
terms and absolute special condition of this contract of insurance that the premium due must be paid and received by the Insurer within sixty
on renewal?
(60) days from
If so, the inception
please date of this Policy/Endorsement/Renewal Certificate.
give full particulars.
If this condition is not complied with, then this contract is automatically cancelled and the Insurer shall be entitled to the pro rata premium for the period
they7. have
Have anyonclaims
been risk. been made upon you during the last
two year in respect of injuries to persons or for Yes No
Where tdamage
he premito umproperty
payable ofputhird
rsuanparties?
t to this warranty is received by an authorised agent of the Insurer, the payment shall be deemed to be received by the
Insurer fIforso,
theplease
purpogive
ses ofull
f thiparticulars
s warranty and
and state nus of proving that the premium payable was received by a person, including an Amount
the oamounts insurance agent, who was
Year Number
paid and
not authorised unpaid. such premium shall lie on the Insurer.
to receive Paid Unpaid
Subject otherwise to the terms and conditions of this Policy.
DECLARATION
GOODS AND SERVICES TAX (GST)
I/We to the WARRANTY
PREMIUM best of my/ouCLAUSE
r knowledge hereby confirm that the statements contained in this proposal form are true and correct and I/We have not concealed,
Goods And Services Tax Notice
mis-represented
It is a fundamentalor mis-stated anyspecial
and absolute material facts. of this contract of insurance that the premium due must be paid and received by the Insurer within sixty
condition
You are advised to review the adequacy of your Sum Insured as Goods and Services Tax (“GST”) may have an impact on your claims settlement as stated below.
(60)
I/We days
agreefrom
thatthe
thisinception
statemendate
ts anof
d this
declaPolicy/Endorsement/Renewal
ration contained in this propCertificate.
osal form shall be the basis of the contract of insurance with the Company and are
deemed to be incorporated in the contract.
Goods And Services Tax Impact On Claims Settlement
If this condition is not complied with, then this contract is automatically cancelled and the Insurer shall be entitled to the pro rata premium for the period
they have been on risk.
Claims Settlement
Where the premium payable pursuant to this warranty is received by an authorised agent of the Insurer, the payment shall be deemed to be received by the
We
Datewill indemnify you on claims made by third party inclusive of the GST, up to the Limit of Indemnity....................................................................................................
Insurer for the purposes of this warranty and the onus of proving that the premium payable was received by a person, including an insurance agent, who was
Day to receive
not authorised Month such premium Year shall lie on the Insurer. Signature of Proposer / Company's Chop
In the event that you are entitled to claim for the Input Tax Credit and if we make a payment under this policy as compensation to you, we will reduce the amount of the payment
by deducting
Subject your Input
otherwise Taxterms
to the Creditand
entitlement irrespective
conditions of whether you have or have not claimed the Input Tax Credit, up to the Limit of Indemnity.
of this Policy.
DECLARATION ON THE VERIFICATION OF AN INSURED IN COMPLIANCE WITH SECTION 16(2) OF THE ANTI-MONEY LAUNDERING ACT 2001
IDECLARATION
______________________________________________ bearing NRIC number _____________________________ an *employee / agent of Allianz General
I/We to the best of my/our knowledge hereby confirm that the statements contained in this proposal form are true and correct and I/We have not concealed,
Insurance Company
mis-represented (Malaysia)
or mis-stated Berhad
any hereby
material facts.certify that the Proposer's original NRIC / Business Registration Certification for _______________________
_______________________________________was verified and authenticated by me at the point of sales.
I/We agree that this statements and declaration contained in this proposal form shall be the basis of the contract of insurance with the Company and are
Ideemed to be incorporated
further confirm in the documents
that the relevant contract. were sighted and verified and the Insured is not suspected of money laundering or financing of terrorism.
Signature : __________________________________
Date ...................................................................................................
Day: __________________________________
Month Year Signature of Proposer / Company's Chop
Date
2.
Customer Service : Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel: 03-2264 0700 Fax: 03-2264 0602 Toll Free : 1-300-88-1028 [email protected]
3.
3.
2.
Updated 09/09
Ibu3.Pejabat
Ibu Pejabat : Suite :3A-15, Level29,
Tingkat 15,Menara
Block 3A,Allianz
Plaza Sentral, Jalan
Sentral, Stesen
203, Sentral
Jalan 5, Kuala LumpurKuala
Tun Sambanthan, Sentral,Lumpur
50470 Kuala Lumpur.
Sentral, 50470 Kuala Lumpur. Tel : 03-2264 1188 / 03-2264 0688 Fax : 03-2264 1199 www.allianz.com.my
Customer Service : Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel: 03-2264 0700 Fax: 03-2264 0602 Toll Free : 1-300-88-1028 [email protected]
Tel : +603 2264 1188 / 2264 0688 Faks: +603 2264 1199 www.allianz.com.my www.facebook.com/AllianzMalaysia Updated 09/09
Ibu Pejabat
Ibu Pejabat : Suite 3A-15, Level 15, Block 3A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470
: Suite 3A-15, Level 15, Block 3A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur.Kuala Lumpur. Tel :Tel
03-2264 1188
: 03-2264 / 03-2264
1188 / 03-2264 0688 FaxFax
0688 : 03-2264 1199
: 03-2264 1199www.allianz.com.my
www.allianz.com.my
Customer
CustomerService
Khidmat Service::Ground
Pelanggan Ground Floor,
: AllianzBlock
Floor, Block 2A,Plaza
Arena,
2A, PlazaSentral,
Sentral,
Tingkat Bawah, Jalan
Jalan BlokStesen
Stesen 2A, Sentral
Plaza
Sentral 5, Kuala
5,Sentral,
Kuala Lumpur
Jalan
Lumpur Sentral,
Stesen
Sentral, 50470
Sentral
50470 Kuala
5, Kuala
Kuala Lumpur.
Lumpur
Lumpur. Tel: 03-2264
Sentral, 0700
50470
Tel: 03-2264 Fax:
0700 03-2264
Kuala
Fax: 0602
Lumpur.
03-2264 TollToll
0602 Free : 1-300-88-1028
Free : [email protected]
[email protected]
Updated
Updated09/09
09/09
Pusat Khidmat Pelanggan Allianz: 1 300 88 1028 Faks: +603 2264 8499 Emel: [email protected]
1. Adakah Loji dan Jenteranya disimpan dalam keadaan Ya Tidak
yang baik dan sempurna ataupun sebaliknya dijaga
menurut keperluan pihak Kerajaan ?
3.
6. (a) Terdapatkah
Pernah mana-manaapa-apa
Syarikatdandang
Insurans atau kebuk tekanan (a) Ya Tidak
yang digunakan
(a) menolak cadangan di Premis
anda ? ini? (a) Ya Tidak
(b) Adakah ia diinsuranskan terhadap kerosakan atau (b) Ya Tidak
(b) enggan membaharui polisi anda ? (b) Ya Tidak
letupan?
(c) (c)
Jika ya,membatalkan polisi anda
sila berikan butiran ?
sepenuhnya. Ya Tidak
(d) menghendaki kadar yang dinaikkan atau mengenakan (d) Ya Tidak
4. terma-terma
Sila sebutkan khas kimia,
asid, gas, untuk bahan
pembaharuan
letupan polisi anda?
atau bahan-
bahan
Jika ya,merbahaya lain apakah
berikan butiran yang akan digunakan dan
sepenuhnya.
ke takat mana ?
7. Pernahkah sebarang tuntutan dibuat terhadap anda selama Ya Tidak
5. d ua tahuanda
Adakah n yakini
ng lediinsuranskan
pas bagi keceterhadap
deraan ksebarang
e atas serisiko
siapa
sahaja atau anda
kerosakan ke atassekarang?
harta pihak Ya Tidak
yang ingin insuranskan Jikaketiga ?
ya, sila Amaun
Jika ya, butiran
berikan sila berikan butiran sepenuhnya serta nyatakan
sepenuhnya. Tahun Bilangan
amaun yang telah dan belum dibayar. Dibayar Belum Dibayar
6. Pernah mana-mana Syarikat Insurans
(a) menolak cadangan anda ? (a) Ya Tidak
(b) enggan membaharui polisi anda ? (b) Ya Tidak
FASAL WARANTI
(c) membatalkan PREMIUM polisi anda ? (c) Ya Tidak
Telah me(d)njadimenghendaki
syarat khas ykadar
ang uyang
tamadinaikkan
dan mutatau
lak bmengenakan
agi kontrak insur(d)
ans ini baYa
hawa premium Tidak
yang mesti dibayar hendaklah dibayar dan diterima oleh pihak
penanggung insurans dalam masa enam puluh (60) hari dari tarikh Polisi/Pengendorsan/Sijil Pembaharuan ini mula berkuat kuasa.
terma-terma khas untuk pembaharuan polisi anda?
Jika syarJika
at taya,
di berikan
tidak dipbutiran
atuhi, ksepenuhnya.
ontrak insurans ini akan terbatal secara automatik dan pihak penanggung insurans akan diberi hak ke atas premium secara
prorata bagi tempoh yang melindungi risiko.
7. Pernahkah sebarang tuntutan dibuat terhadap anda selama Ya Tidak
Jikalau premium
dua tahunyang yangdibayar
lepas menurut
bagi kecewaranti
deraan ini
ke diterima
atas sesiaoleh
pa seorang ejen berkuasa pihak penanggung insurans, bayaran tersebut hendaklah disifat kan
telah ditsahaja
erima oatau
leh pkerosakan
ihak penankeggatas
ung harta
insurapihak
ns bagketiga
i tujua?n-tujuan waranti ini manakala kewajipan (ONUS) untuk membuktikan bahawa premium yang dibayar
Amaun
itu telahJika
diterima
ya, silaoleh seseorang,
berikan butiran termasuk ejen insurans,
sepenuhnya yang tidak diberi
serta nyatakan kuasa untuk menerima
Tahun premium berkenaan adalah terletak pada pihak penang-
Bilangan
gung insurans.
amaun yang telah dan belum dibayar. Dibayar Belum Dibayar
Tertakluk kepada terma-terma dan syarat-syarat Polisi ini ataupun sebaliknya.
PENGISYTIHARAN
CUKAI BARANGAN DAN PERKHIDMATAN (GST)
FASAL WARANTI
Saya/Kam i dengan iPREMIUM
Notis Cukai ni mengesahkan bahawa menurut apa yang saya/kami sesungguhnya ketahui, pernyataan yang terkandung dalam borang cadangan ini
Barangan Dan Perkhidmatan
Tadalah
elah mbetul
enjaddan
i syabenar
rat khadan
s yasaya/kami
ng utama d tidak
an mmenyelindung,
utlak bagi kontsalah
rak inmenyatakan
surans ini baatau
hawasalah
premmemberikan
ium yang mesebarang
sti dibayafakta
r henmatan.
daklah dibayar dan diterima oleh pihak
Anda dinasihati
penanggung untuk dalam
insurans mengkaji
masakecukupan
enam puluh Jumlah
(60)Diinsuranskan anda
hari dari tarikh kerana Cukai Barangan
Polisi/Pengendorsan/Sijil dan Perkhidmatan
Pembaharuan ini mulaboleh memberi
berkuat kuasa.kesan kepada penyelesaian
Stuntutan
aya/Kamanda
i bersseperti
etuju bdibawah.
ahawa pernyataan dan akuan yang terkandung dalam borang cadangan ini hendaklah dijadikan asas kontrak bagi insurans ini dengan
Jpihak
ika sySyarikat
arat tadidan
tidaia
k djuga
ipatuhendaklah
hi, kontrakdisifatkan
insurans telah
ini akdigabungkan
an terbatal sedalam
cara akontrak
utomatikini.dan pihak penanggung insurans akan diberi hak ke atas premium secara
Kesan Cukai
prorata Barangan
bagi tempoh yangDan Perkhidmatan
melindungi risiko. Terhadap Penyelesaian Tuntutan
Impak Cukai
Jikalau Barangan dan Perkhidmatan terhadap Penyelesaian Tuntutan
Tarikh premium yang dibayar menurut waranti ini diterima oleh seorang ejen berkuasa pihak...................................................................................................
penanggung insurans, bayaran tersebut hendaklah disifat kan
tKami
elah akan
diterim a oleh piharugi
menangung k peanda
nanguntuk
gung ituntutan
nsurans byang
agi tdi
ujubuat
an-tuoleh
juanpihak
waraketiga
nti ini (termasuk
manakala kCukai
ewajiBarangan
pan (ONUdan
STandatangan
) uPerkhidmatan),
ntuk membPencadang
uktiksehingga
an baha/ w a prSyarikat
Had
Cop emium yaRugi.
Tanggung ng dibayar
Hari Bulan Tahun
itu telah diterima oleh seseorang, termasuk ejen insurans, yang tidak diberi kuasa untuk menerima premium berkenaan adalah terletak pada pihak penang-
Sekiranya
gung anda layak membuat tuntutan bagi Kredit Cukai Input dan jika kami membuat pembayaran di bawah polisi ini sebagai pampasan kepada anda, kami akan
insurans.
mengurangkan
KENYATAAN jumlah bayaran dengan
PENGESAHAN menolak kelayakan
PIHAK DIINSURANSKAN InputDENGAN
SELARAS Kredit Cukai anda tidak
PEMATUHAN kira sama
SEKSYEN adaAKTA
16(2) andaPENCEGAHAN
menuntut atau tidak Kredit Cukai
PENGUBAHAN WANGInput, HARAM sehingga
2001 Had
Tertakluk
Tanggungkepada
Rugi. terma-terma dan syarat-syarat Polisi ini ataupun sebaliknya.
Saya _______________________________________________ (No. KP : ______________________), *kakitangan/ejen Allianz General Insurance
PENGISYTIHARAN
Company
Saya/Kami (dM
enaglaaynsiian)i Bmeernhgaedsadheknag
nabnah
inaiwm
a em
negneusaruhtkaan
pabyaahnagwsaayNao/m
kab
moi r sK
esaudng
Pgeunhgneynaalkaenta/Shiujii,l PpeernndyaafttaaarnanyaPnegrnteiarg
kaanadnunag
saldapleam
mobhoornanygancagdb
anegrn
anaminai
__________________________________________________________
adalah betul dan benar dan saya/kami tidak menyelindung, salah menyatakan telah disahkan
atau salahketulenannya
memberikan ketika sebarang urusniaga dijalankan.
fakta matan.
Saya/juga
Saya Kamimengesahkan
bersetuju bahdokumen-dokumen
awa pernyataan dan yang
akuarelevan
n yang telah
terkandisahkan
dung dalketulenannya
am borang cadangPihak
dan an iniDiinsuranskan
hendaklah dijatidak
dikandisyaki
asas kdalam
ontrakaktiviti
bagi inpengubahan
surans ini dewang
ngan
pihak Syarikat dan ia juga hendaklah disifatkan telah digabungkan dalam kontrak ini.
haram atau pembiayaan keganasan.
Tarikh
Tandatangan : __________________________________ ...................................................................................................
Hari Bulan Tahun Tandatangan Pencadang / Cop Syarikat
Tarikh : __________________________________
*Potong yang manaPENGESAHAN
KENYATAAN tidak berkenaan.
PIHAK DIINSURANSKAN SELARAS DENGAN PEMATUHAN SEKSYEN 16(2) AKTA PENCEGAHAN PENGUBAHAN WANG HARAM 2001