PACIFIC & ORIENT INSURANCE CO.

BERHAD
Registration No. 197201000959 (12557-W)
A Member Of The Pacific & Orient Group
SST Registration No. / No. CP : W10-1808-31021805
th
11 Floor, Wisma Bumi Raya, No. 10, Jalan Raja Laut, 50350 Kuala Lumpur.
P.O.Box 10953, 50730 Kuala Lumpur. Internet: www.pacific-orient.com / https:// www.poi2u.com
Telephone: 03 - 2698 5033 Fax: 03 - 2693 8145 Auto Assist Toll Free: 1 800 88 2121 ORIGINAL

PRIVATE CAR POLICY SCHEDULE / JADUAL POLISI

Agent Name / Address / Tel No. / Nama Ejen /Alamat / No. Tel Agent Code / Kod Ejen 32314-01-C
KERJAYA POLISI SDN BHD
D-17-05 MENARA MITRALAND Batch No. / No. Kumpulan 09*MT-648816
NO. 13A, JALAN PJU 5/1
KOTA DAMANSARA PJU5
New Policy No. / No. Policy Baru 01-01-20-LBF-027158
03-76606606
The Insured / Address / Pihak Diinsuranskan / Alamat
SAHROL NIZAM BIN AMAN Old Policy No. / No. Policy Lama
DAZA VILLA
LOT 9258 JALAN KAMPUNG PEREPAT, KAPAR Date / Time of Issue /
16-09-2020 10:49pm
42200 SELANGOR SELANGOR Tarikh / Masa Dikeluarkan
Geographical Area / Kawasan Geografi: Malaysia, Republic of Singapore and Negara Brunei Darussalam The Policy Premium (RM) / Premium Polisi (RM)
Business / Profession/ Perniagaan / Pekerjaan Sum Insured /Jumlah Diinsuranskan 14,000.00
New IC No./ Business Registration No. Trailer Sum Insured /
750720-10-5357
No. KP Baru / No. Pendaftaran Perniagaan Jumlah Diinsuranskan Bagi Treler
Excess Applicable /
Old IC No. / No. Kad Pengenalan Lama 140.00
Lebihan Yang Dikenakan
Cover Granted /
Gender / Jantina MALE COMPREHENSIVE
Jenis Perlindungan Yang Diberi
Quotation Date /Tarikh
Quotation No /No Sebutharga
Marital Status / Taraf Perkahwinan MARRIED Sebutharga
QUO2009113624
16-09-2020
Type of Usage / Jenis Kegunaan PRIVATE CAR Basic Premium / Premium Asas 900.62
Period of Insurance / Tempoh Insurans Inclusive Of /Termasuk
From/Dari 16-09-2020 10:49pm To/Hingga 15-09-2021 Midnight/Tgh Malam All Riders (M/cycle) /
12:00am Semua Penunggang (M/sikal)
Class of Vehicle / Kelas Kenderaan PRIVATE CAR EX GOODS
Hire Purchase / Sewa Beli NCD / DTT ( 45.00% ) 405.28
Regn. Card No./Trailer Regn. Card No. NCD Effective Date ( 16-09-2020 )
No.Perakuan Pendaftaran Kenderaan/Treler Tarikh Berkuatkuasa DTT
Vehicle Registration No./ Extra Benefits / Perlindungan Tambahan
WJU9008 :-
No. Pendaftaran Kenderaan

Trailer Registration No/No Pendaftaran Treler

FORD RANGER EXTREME

Make & Type of Body / Buatan & Jenis Badan
4 SP~
Cubic Capacity / Keupayaan Enjin 2,499.00 CC
Year of Manufacture / Tahun Diperbuat 2001
Seating Capacity (including driver) Gross Premium / Premium Kasar 495.34
5
Muatan Tempat Duduk (Termasuk Pemandu)
Engine No. / No. Enjin WL270408
Chassis No. / No. Casis SZCW1D95156 Service Tax / Cukai Perkhidmatan 29.72
Trailer Chassis No. / No. Casis Treler GST / GST 0.00
SST Registration No. / No. Pendaftaran CP Stamp Duty / Duti Setem 10.00
Named Driver(s) / Pemandu yang Diberi Kuasa Total Premium / Jumlah Premium 535.06
THE POLICYHOLDER
Amount Payable (Rounded) / Jumlah Perlu
535.05
Dibayar (Digenapkan)
Act Premium / Premium Akta 115.77
Limitation as to use: As per Certificate of Insurance attached / Had Penggunaan: Seperti Sijil Insuran yang disertakan
Subject to following clauses printed herein or attached hereto / Tertakluk kepada fasal-fasal dicetak atau dikepil disini
Endorsement / Pengendorsan Include Endt No : ,2
LEGISLATION / PERUNDANGAN
Road Trans port Ac t, 1987(Malay s ia) Motor Vehic les (Third-Party Ris k s and Compens ation) Ac t (Cap 189) Republic of Singapore Motor Vehic les (Third Party Ris k and Compens ation) Rules (Republic of
Singapore) Motor Vehic les Ins uranc e (Third Party Ris k s ) Ac t (Cap90) Negara Brunei Darus s alam (the referenc e to legis lation under the heading “Av oidanc e of Certain Terms and Right of Rec ov ery is
limited to Sec tion 94, 95 and 96 of the Road Trans port Ac t 1987 (Malay s ia) Sec tion 7,8 and 9 of the Motor Vehic les (Third Party Ris k s and Compens ation) Ac t (Cap 189) Republic of Singapore and
Sec tion 7 of the Motor Vehic les Ins uranc e (Third Party Ris k s ) Ac t (Cap 90) Negara Brunei Darus s alam.
Important Notice: For environmental conservation, we no longer print the policy wording/fact sheet/pocket sized card/directory of panel workshop/important notice/notice to all policyholders. You may
view the documents terms/conditions of the above stated policy number at www.pacific-orient.com A print out of your Policy can obtained from our branch office located nationwide or from your
servicing agents.
Kenyataan Penting: Untuk pemeliharaan alam sekitar, kami tidak lagi mencetak butir-butir polisi/lembaran fakta/kad saiz poket/panduan bengkel penal membaiki kenderaan/notis mustahak/notis
kepada pemegang polisi. Anda boleh membaca dokumen-dokumen terma/syarat untuk dokumen polisi bernombor diatas di www.pacific-orient.com Cetakan polisi anda boleh diperolehi daripada
pejabat cawangan kami di seluruh negara ataupun ejen Pacifc & Orient anda.
You are required to read the Notice in regard to your Personal Data or Sensitive Personal Data. The notice is in Our Website. Please go to www.pacific-orient.com .
*Anda diarahkan untuk membaca Notis berkenaan Data Peribadi atau Data Peribadi Sensitif anda. Notis tersebut boleh didapati di Laman Sesawang kami. Sila lawati www.pacifc-orient.com
***THIS IS A COMPUTER GENERATED DOCUMENT AND IT DOES NOT REQUIRE SIGNATURE*** THIS DOCUMENT SHALL NOT BE INVALIDATED SOLELY ON THE GROUND THAT IT IS NOT SIGNED.
***INI ADALAH DOKUMEN YANG DIKELUARKAN OLEH KOMPUTER DAN TANDATANGAN TIDAK DIPERLUKAN*** DOKUMEN INI TIDAK HARUS DITAKSAHKAN SEMATA-MATA ATAS ALASAN IA TIDAK DITANDATANGANI.
MOTOR POLICY SCHEDULE…..(1 of 2) REPRINTED 16-09-2020 10:49pm 2 PS AGENT ODC
 Certificate of Insurance/Sijil
Insuran GST Reg. No/No CBP : 001055457280
ORIGINAL
ROAD TRANSPORT ACT, 1987 (MALAYSIA) / AKTA PENGANGKUTAN JALANRAYA 1987 (MALAYSIA)
MOTOR VEHICLES (THIRD PARTY RISKS) RULES, 1959 (MALAYSIA)/PERATURAN-PERATURAN KENDERAAN BERINJIN (RISIKO KE ATAS PIHAK KETIGA) 1959 (MALAYSIA)
MOTOR VEHICLES (THIRD PARTY RISKS AND COMPENSATION) ACT (CAP 189) (REPUBLIC OF SINGAPORE)/ORDINAN KENDERAAN BERINJIN
(RISIKO KE ATAS PIHAK KETIGA DAN PAMPASAN) No.1 1960 (REPUBLIK SINGAPURA)
MOTOR VEHICLES (THIRD PARTY RISKS AND COMPENSATION) RULES 1960 (REPUBLIC OF SINGAPORE) / PERATURAN-PERATURAN KENDERAAN BERINJIN
(RISIKO KEATAS PIHAK KETIGA DAN PAMPASAN) 1960 (REPUBLIK SINGAPURA)
MOTOR VEHICLES INSURANCE (THIRD PARTY RISKS) ACT (CAP-90) (NEGARA BRUNEI DARUSSALAM)/PERATURAN-PERATURAN KENDERAAN BERINJIN
(RISIKO KEATAS PIHAK KETIGA) ENAKMEN 1950 (BRUNEI DARUSSALAM)

CERTIFICATE NO. / NO SIJIL 010120LBF027158 C.I Code / Kod Sijil Insurans : M.X.1
Agent Code : 32314-01-C Agent Name : KERJAYA POLISI SDN BHD
1. Registration No. / No. Pendaftaran : WJU9008 Cover Type / Jenis Perlindungan: COMPREHENSIVE
2. Name of Policyholder / Nama Pemegang Polisi : SAHROL NIZAM BIN AMAN
3. Excess/Lebihan: RM140.00 Sum Insured/Jumlah Diinsuranskan: RM14,000.00 NCB / DTT: 45.00%
4. Hire Purchase / Sewa Beli : Wef: 16-09-2020
5. Effective Date and Time of Commencement of Insurance for the purpose of the Ordinance 16-09-2020 10:49pm
/:
Tarikh dan Masa Permulaan Insurance bagi tujuan Ordinan
6. Date and Time of Expiry of the Insurance / Tarikh dan Masa Tamat Insuran: 15-09-2021 12:00am
7. Person or Classes or 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
a Court of Law or by reason of any enactment or Regulations in behalf from driving the Motor Vehicle. / Dengan syarat orang tersebut dibenarkan memandu menurut undang-undang
perlesenan atau undang-undang lain atau peraturan untuk memandu Kenderaan Bermotor tersebut atau telah dibenarkan dan tidak dilucutkan kelayakannya diatas perintah Mahkamah
atau oleh sebab mana-mana enakmen atau peraturan daripada memandu Kenderaan Bermotor tersebut

8. Limitation 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, pacemaking, reliability trail, speed-testing, the carriage of goods
other than samples in connection with any trade or business or use for any purpose in connection with Motor Trade.

Digunakan hanya untuk tujuan social, domestic dan persiaran and 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 atau
digunakan
untuk apa-apa tujuan yang berkaitan dengan Perdagangan Motor.

* Limitation 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. Pengehadan
dijadikan tidak berkuat kuasa oleh Seksyen 95 Akta Pengangkutan Jalan 1987 (Malaysia) atau 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 tidak termasuk di bawah tajuk ini.

I/We hereby certify that the Policy to which the Certificate relates is issued in accordance with the Provisions of Party IV of the Road Transport Act, 1987 (Malaysia), The Motor Vehicles
(Third Party Risks and Compensation) Ordinance 1960 (Republic of Singapore) and The Motor Vehicles Insurance (Third Party Risks) Enactment 1950 (State of Brunei)
Saya/Kami dengan ini mengaku bahawa Polisi yang berhubung dengan Sijil ini adalah di keluarkan mengikut Bahagian IV peruntukan-peruntukan Akta Pengangkutan Jalanraya 1987
(Malaysia), Ordinan kenderaan-kenderaan Berinjin (Risiko-Risiko Pihak Ketiga dan Pampasan) 1960 (Republik Singapura) dan Insuran Kenderaan Berinjin (Risiko Bagi Pihak Ketiga)
Enakmen 1950 (Negara Brunei Darussalam.)

You are required to read the Notice in regard to your Personal Data or Sensitive Personal Data. The notice is in Our Website. Please go to www.pacific-orient.com .
Anda diarahkan untuk membaca Notis berkenaan Data Peribadi atau Data Peribadi Sensitif anda. Notis tersebut boleh didapati di Laman Sesawang kami. Sila lawati www.pacifc-orient.com

***THIS IS A COMPUTER GENERATED DOCUMENT AND IT DOES NOT REQUIRE SIGNATURE*** THIS DOCUMENT SHALL NOT BE INVALIDATED SOLELY ON THE GROUND THAT IT IS NOT SIGNED.
***INI ADALAH DOKUMEN YANG DIKELUARKAN OLEH KOMPUTER DAN TANDATANGAN TIDAK DIPERLUKAN*** DOKUMEN INI TIDAK HARUS DITAKSAHKAN SEMATA-MATA ATAS ALASAN IA TIDAK DITANDATANGANI.

MOTOR POLICY SCHEDULE…..(2 of 2) 3 COI ODC

 PACIFIC & ORIENT INSURANCE CO. BERHAD
Registration No. 197201000959 (12557-W)
A Member Of The Pacific & Orient Group
SST Registration No. / No. CP : W10-1808-31021805
th
11 Floor, Wisma Bumi Raya, No. 10, Jalan Raja Laut, 50350 Kuala Lumpur.
P.O.Box 10953, 50730 Kuala Lumpur. Internet: www.pacific-orient.com / https://www.poi2u.com
Telephone: 03 - 2698 5033 Fax: 03 - 2693 8145 Toll Free: 1 800 88 2121

PROPOSAL FORM
MOTOR PROPOSAL FORM / BORANG CADANGAN KENDERAAN
The Insured / Address / Pihak Diinsuranskan / Alamat Agent Code / Kod Ejen 32314-01-C
SAHROL NIZAM BIN AMAN
DAZA VILLA Agent Name / Address / Nama / Alamat Ejen
LOT 9258 JALAN KAMPUNG PEREPAT, KAPAR KERJAYA POLISI SDN BHD
42200 SELANGOR SELANGOR
D-17-05 MENARA MITRALAND NO. 13A, JALAN PJU 5/1 KOTA DAMANSARA PJU5

Tel No. / No. Tel 03-76606606 Fax No. / No. Faks

Potential Policy No. / Date / Time of Proposal
01-01-20-LBF-027158 16-09-2020 10:49PM
No. Polisi Potensi : Tarikh / Masa Cadangan
Geographical Area / Kawasan Geografi: Malaysia, Republic of Singapore and Negara Brunei Darussalam
Business Reg. No. / No.
(Old/Lama)
NRIC No./ Business Regn No. Pendaftaran Sykt.
No.KP / No. Pendaftaran Syarikat
(New/Baru) 750720-10-5357 Gender / Jantina MALE

Insured Information / Date Of Birth / Tarikh Lahir 20-07-1975 Age / Umur 45

Butiran Pencadang Occupation / Trade Marital Status /
MARRIED
Pekerjaan / Perniagaan Taraf Perkahwinan
Tel. No. (House) / No. Office / Hand phone /
Tel. (Rumah) Pejabat Telefon Bimbit
E-mail
Please Mark [ X ] In Appropriate Column / Sila Tandakan [ X ] Diruangan Berkaitan
Period Of Insurance / To Midnight / Hingga
Policy Coverage / From / Dari 16-09-2020 15-09-2021
Tempoh Insurans Tgh Mlm
Butiran
Type Of Coverage / Comprehensive/ Third Party / Third Party (Fire & Theft) /
Perlindungan
Jenis Perlindungan Komprehensif Pihak Ketiga Pihak Ketiga (Kebakaran & Kecurian)
Hire Purchase Owner / Pemilik Sewa Beli
Authorised Driver / Rider /Pemandu Yang Dibenarkan THE POLICYHOLDER
Insured Only / All Riders / Commercial Use/
Pemegang Polisi Sahaja Semua Penunggang Kegunaan Perdagangan
All Drivers / Legal Liability to Passengers / Legal Liability Of Passengers /
Semua Pemandu Perlindungan Kepada Penumpang Perlindungan Dari Penumpang
Strike, Riot & Civil Commotion / Mogok Windstorm / Flood Tuition Purpose /
Extended Cover / Dan Rusuhan Ribut / Banjir Tujuan Tuisyen
Perlindungan Windscreen / Tinted Film Screen / Others (Please Specify)
Tambahan Cermin RM Filem penapis skrin RM Lain-Lain
Radio / Cassette Player (Please Specify) Gas Conversion Kit & Tank /
/ Radio / Pemain Kaset Peralatan Penukaran Gas & Tangki

Credit Shortfall /
Original HP Term
Kekurangan Kredit
Make & Model / Registration No. /
FORD RANGER EXTREME 4 SP AUTO~ WJU9008
Buatan / Model No. Pendaftaran
Engine No. / Trailer No /
WL270408
No. Enjin No. Treler
Chassis No. / Year Of Make /
SZCW1D95156 2001
No. Casis Tahun Diperbuat
Cubic Capacity / Date Of Purchase /
2499.00 CC
Kuasa Injin Tarikh Belian
Seating Capacity / Purchase Price (RM) /
5
Muatan Tempat Duduk Harga Belian (RM)
Use of Vehicle / Sum Insured (RM) /
PRIVATE CAR EX GOODS 14,000.00
Kegunaan Kenderaan Nilai Diinsuranskan (RM)
Vehicle Description/ Trailer Sum Insured (RM) /
Butiran Kenderaan Nilai Insurans Treler (RM)
Place Where The Vehicle Will Normally Be Garaged / Tempat Kenderaan Biasanya Ditempatkan
Roadside – Public Parking Roadside – Outside Residence
Kawasan Meletak Awam – Tepi Jalanan Diluar Kawasan Kediaman – Tepi Jalanan
Within Residence Compound Outside Residence Compound
Dalam Kawasan Kediaman Diluar Kawasan Kediaman
Parking Lot (Open) Parking Lot (Covered)
Kawasan Letak Kereta (Terbuka) Kawasan Letak Kereta (Tertutup)
Anti Theft Device / Alat Pencegah Kecurian Safety Features / Ciri-ciri Keselamatan
Factory Fitted Alarm / Airbags Installed /
Immobilizer
Penggera Buatan Kilang Pemasangan Beg Udara
Stearing or Gear Lock / ABS Breaking System Installed /
GPRS
Pengunci Stereng atau Gear Pemasangan Sistem Brek ABS

PROPOSAL FORM…..(1 of 4)
 Has the vehicle been altered/modified/changed in any way (including optional extras) from the vehicle manufacturer’s standard
specification: / Pernahkah kenderaan ini diubah/diubahsuai/ditukar dalam apa-apa cara (termasuk pilihan tambahan) dari
spesifikasi asas pengeluar kenderaan:
Changes to the bodywork, such as spoilers or body kits/ Perubahan pada kerja badan seperti spoiler atau kit
badan
Modification / Changes to suspension or brakes / Perubahan pada suspensi atau brek
Pengubahsuaian Cosmetic changes such as alloy wheels or paint / Perubahan kosmetik seperti roda aloi atau cat
Changes affecting performance such as changes to the engine management system or exhaust system / Perubahan
mempengaruhi prestasi seperti perubahan kepada sistem pengurusan enjin atau sistem ekzos
Changes to the audio/entertainment system / Perubahan pada sistem audio/hiburan
Please take note that this is not a full list of all possible changes - all changes made from the vehicle manufacturer’s standard
specification must be disclosed/ Sila ambil perhatian bahawa ini tidak merupakan senarai penuh segala perubahan mungkin
semua perubahan dibuat daripada spesifikasi asas pengeluar kenderaan haruslah dinyatakan.
Please [ X ] In Appropriate Column / Sila [ X ] Diruangan Berkaitan
Private Car / Commercial Vehicles /
Motorcycle / Motorsikal Taxi / Teksi Buses / Bas
Kenderaan Persendirian Kenderaan Perdagangan
Private Social &
“A” Permit Single Rider Town / Outstation School
Domestic Purpose

Company Purpose “C” Permit All Riders Airport Limousine Factory (Hire & Reward)

Special Type
Commercial Use Hire Car Factory ( Carriage of Own Workers )
(Please Specify)
Other (Please Other (Please Other (Please Other (Please
Other (Please Specify)
Specify) Specify) Specify) Specify)

PASSANGERS DRIVER PLAN (PDP)

If you have been insured during the past 12 months please state /
No Claim Sila nyatakan jika ada perlindungan Insurans sepanjang tempoh 12 bulan yang lalu
Discount Name of Insurer / Policy No. /
(NCD) Nama Syarikat Insurance No. Polisi
Entitlement /
Kelayakan Vehicle Registration No. / No Claim Discount / Diskaun
WJU9008 %
Diskaun No. Pendaftaran Kenderaan Tanpa Tuntutan
Tanpa From /
Tuntutan Period of Insurance/Tempoh Insurans To / Hingga
Dari
(DTT)
Pleas e enc los e the Original Polic y Sc hedule / Renewal Notic e / Certific ate Of Ins uranc e / Endors ement with NCD s tatus to s upport y our entitlement and s ign the Letter of Undertak ing
Sila lampirkan Polisi Asal / Notis Pembaharuan / Sijil Insurans / Pengendorsan yang menunjukkan Diskaun Tanpa Tuntutan dan menandatangani Surat Akuan Pengesahan.

During The Past Three Years have you or any persons who may drive (answer YES or NO) /
Sepanjang tempoh Tiga Tahun yang lepas adakah anda atau sesiapa yang pernah memandu (Jawab YA atau TIDAK)
Had any insurance cancelled or refused?
YES / YA NO / TIDAK
Pernah insuransnya dibatal atau ditolak?
Been Convicted of any Traffic Offence?
Claim History Didakwa kerana Kesalahan Lalulintas?
/
Sejarah Had a Driving License endorsed, suspended or cancelled? Pernah
Tuntutan Lesen Memandunya diendors, digantung atau dibatalkan?
Had a accident or claimed on any vehicle policy? Pernah mengalami
kemalangan atau tuntutan pada kenderaan polisinya?
Date of Accident Vehicle No. Name of Insurer Name of Loss / Injury Amount Claimed
Tarikh Kemalangan No. Kenderaan Nama Syarikat Insurans Jenis Kerugian / Kecederaan Jumlah yang dituntut

PROPOSAL FORM…..(2 of 4)
 IMPORTANT NOTICE / KENYATAAN PENTING

Your attention is drawn to Section 141(1) Of the Insurance Act 1996

No cover can be granted until premium has been paid in accordance with the Regulation issued Under this 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 RM500,000.00. Where payment of the premium is made
be cash, cheque, money / postal / cashiers order to bankers draft, The payment must be crossed “Account Payee Only” and made in favour of PACIFIC
& ORIENT INSURANCE CO. BERHAD /
Perhatian tuan pada Seksyen 141(1) Akta Insurans 1996, Yang Dipinda Perlindungan Insurans tidak akan berkuatkuasa melainkan premium
telah dibayar. Kegagalan bagi mematuhi Seksyen ini dianggap satu kesalahan dimana jika disabitkan kesalahan anda boleh dikenakan denda
tidak melebihi RM500,000.00. Bagi pembayaran melalui cek, kiriman wang, wang pos, bank draf atau juruwang hendaklah dipalang dan
dibayar atas nama PACIFIC & ORIENT INSURANCE CO. BERHAD

The Policy Will Be Subject To The Operational Warranties Of This Proposal Form
You are obliged to strictly comply with these warranties. Any breach of any of these Warranties could render the Policy null and void
Polisi Akan Tertakluk Kepada Waranti Yang Diguna Pakai Pada Borang Cadangan Ini.
Anda diwajibkan mematuhi waranti tersebut. Sebarang pelanggaran mana-mana waranti boleh menjadikan Polisi batal dan tidak sah
Insurans Terkurang / Fasal Purata / Nilai Pasaran

Under Insurance / Average Clause / Market Value / Insurans Terkurang / Fasal Purata / Nilai Pasaran
Your attention is also drawn to “Under Insurance”. It is hereby understood and agreed that if your vehicle shall at the time of happening of any loss or
damage be insured for a sum Lesser than its market value then, You shall be considered as being Your own insurer for the Difference and shall bear the
rateable proportion of the loss accordingly. Provided always that this shall not apply unless the market value at the time of the loss exceeds the insured
value by 10%. The market value of a vehicle would be determined in accordance to Section A2 (d), (e) and (f) of the motor policy.
Perhatian tuan pada “Insurans terkurang”. Anda perlu memastikan nilai harga kenderaan anda yang dilindungi selaras dengan nilai pasaran
terkini kenderaan tersebut. Jika tidak, anda terpaksa menanggung sendiri sebahagian daripada kerugian yang anda alami.
Walaubagaimanapun ia tidak akan diguna pakai melainkan nilai pasaran semasa kerugian tuntutan dilaporkan. Nilai pasaran kenderaan
adalah ditentukan menurut Seksyen A2 (d), (e) dan (f) pada polisi motor.

Passenger Liability Cover / Perlindungan Tanggungan Kepada Penumpang

It is an offence under the law of Republic of Singapore to enter the country without extending passenger liability cover to Your motor insurance./
Adalah menjadi satu kesalahan jika memasuki Republik Singapura tanpa Perlindungan Tanggungan kepada Penumpang pada Insurans
Motor anda.

Insurer’s Authorised Workshop / Bengkel Yang Diberi Kuasa Oleh Penanggung Insurans
In the event Your Vehicle is involved in an accident and gives rise to claim. Your Vehicle must be removed to a PIAM Approved Repairers Schedule
(PARS) Workshop Selected and approved by us for repairs. Failure to remove Your Vehicle to an approved workshop would be a breach of Endorsement
106 and We shall have the right to decline liability under Section A of the Policy.
Sekiranya Kenderaan Anda terlibat dalam kemalangan dan menyebabkan tuntutan. Kenderaan Anda mestilah dihantar kepada bengkel Skim
Bengkel Pembaikan Yang Diluluskan oleh PIAM (SBPP) yang dipilih dan diluluskan oleh kami untuk pembaikan. Kegagalan untuk mengalih
Kenderaan Anda ke bengkel yang diluluskan adalah pelanggaran pengendorsan 106 dan kami mempunyai hak untuk menolak liabiliti di
bawah Seksyen A Polisi ini.

Notice On Avenue Of Appeal / Notis Cara Merayu

If you have any complaints of unfair practices by the Company. You may write to Ombudsman Financial Services (OFS)
Sekiranya Anda mempunyai apa-apa aduan mengenai amalan tidak adil oleh Syarikat, Anda boleh menulis kepada Ombudsman Perkhidmatan
Kewangan (OPK).

Consumer Insurance Contract / Kontrak Insurans Pengguna

Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for purposes unrelated to your
trade, business or profession, you have a duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form.
You must answer the questions in this Proposal Form fully and accurately.
Menurut Perenggan 5 daripada Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon insurans ini sepenuhnya untuk tujuan yang
tidak berkaitan perdagangan, perniagaan atau profesion anda, anda mempunyai kewajipan untuk mengambil langkah yang munasabah untuk
tidak salah nyata dalam menjawab soalan-soalan dalam Borang Cadangan ini. Anda dikehendaki menjawab soalan-soalan dalam Borang
Cadangan ini dengan lengkap dan tepat.

Failure to take reasonable care in answering the questions may result in avoidance of your contract of insurance, refusal or reduction of your claim(s),
change of terms or termination of your contract of insurance.
Kegagalan untuk mengambil langkah yang munasabah dalam menjawab soalan-soalan, mungkin mengakibatkan pembatalan kontrak
insurans anda, keengganan atau pengurangan gantirugi, perubahan terma atau penamatan kontrak insurans anda.

The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us.
Kewajipan pendedahan diatas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami.

In addition to answering the questions in this Proposal Form, you are required to disclose any other matter that you know to be relevant to our decision in
accepting the risks and determining the rates and terms to be applied.
Sebagai tambahan kepada soalan-soalan dalam Borang Cadangan ini, anda dikehendaki untuk mendedahkan apa-apa perkara lain yang anda
tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan.

You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the
information given in this Proposal Form is inaccurate or has changed.
Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda
ditandatangani, diubah atau diperbaharui dengan kami, apa-apa maklumat yang dinyatakan
dalam Borang Cadangan ini tidak tepat atau telah berubah.

PROPOSAL FORM…..(3 of 4)
Non-Consumer Insurance Contract / Kontrak Insurans Komersial

Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade,
business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the
rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result
in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance.
Menurut Perenggan 4(1) Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon insurans ini untuk tujuan yang
berkaitan dengan perdagangan, perniagaan atau profesion anda, anda berkewajipan untuk mendedahkan apa-apa perkara yang
anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan, dan apa-
apa perkara yang munasabah yang boleh dijangka, jika tidak ia boleh menyebabkan pembatalan kontrak insurans, keengganan
atau pengurangan ganti rugi, perubahan terma atau penamatan kontrak insurans anda.
The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us.
Kewajipan pendedahan diatas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan
kami.
You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the
information given in this Proposal Form is inaccurate or has changed.
Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans
anda ditandatangani, diubah atau diperbaharui dengan kami, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini
tidak tepat atau telah berubah.

We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the question in this Proposal Form and I/we
hereby declare that I/we have full and accurately answered the question above.

Saya/Kami faham bahawa menjadi tanggungjawab saya/kami untuk mengambil langkah yang munasabah untuk tidak salah nyata semasa
menjawab soalan-soalan dalam Borang Cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab dengan
sepenuhnya dan dengan tepat soalan di atas

I/We understand that My/Our Personal Data or Sensitive Personal Data (“PD” or “SPD” given by Me/Us is required to use to process My/Our application
for insurance cover or Claims processing. I/We also affirm that the Policy’s named driver(s) have given their consent to Me/Us to disclose his/her/their
PD or SPD and that I/We have given He/She/Them due notice. I/We acknowledge notice of the propose use of My/Our PD or SPD and hereby explicitly
consent to the use of the PD or SPD collected or held by the Company to be used, processed and disclosed to individuals or companies as may be
required to issue or comply with the terms, conditions and obligations under the Policy. I/We also agree that the Company can also use, process and
disclose to any related company, insurer or reinsurer in Malaysia or abroad any selected third party service providers. We deem necessary any
Regulatory body/governing Authority/Association/federation of insurance companies, any corporate entities, governmental, legal, regulatory, judicial bodies
or their service providers to whom the Company, its affiliates or any third party data processor is obliged to disclose by requirement of any law, bye-law or
guideline. I/We also acknowledge that I can obtain access to information of third party Data Processors or correct or halt the processing of My/Our PD or
SPD at any time by written request stating your contract particulars and particulars of the said request

Saya/Kami memahami bahawa Data Peribadi atau Data Peribadi Sensitif (“DP” atau “DPS”) Saya/Kami yang diberikan oleh Saya/Kami adalah
diperlukan untuk kegunaan bagi memproses permohonan pelindungan atau tuntutan insurans Saya/Kami. Saya/Kami juga mengesahkan
bahawa pemandu di dalam Polisi itu telah memberikan keizinan mereka kepada Saya/Kami untuk mendedahkan DP atau DPS beliau/mereka
dan bahawa Saya/Kami telah memberikan Penama itu notis sewajarnya. Saya/Kami mengakui notis tujuan penggunaan DP atau DPS
Saya/Kami dan dengan ini secara eksplisit membenarkan penggunaan DP atau DPS yang dikumpul atau dipegang oleh Syarikat untuk
digunakan, diproses dan didedahkan kepada individu atau syarikat yang mungkin diperlukan untuk mengeluarkan atau mematuhi syarat-
syarat dan kewajipan di bawah Polisi. Saya/Kami juga bersetuju bahawa Syarikat juga boleh menggunakan, memproses dan mendedahkan
kepada mana-mana syarikat yang berkaitan, syarikat insurans atau syarikat insurans semula di Malaysia atau di luar Negara atau mana-mana
penyedia perkhidmatan pihak ketiga yang terpilih. Kami menganggap perlu mana-mana badan Berkanun/pihak
Berkuasa/Persatuan/Persekutuan syarikat insurans, mana-mana entiti korporat, kerajaan, guaman, badan berkanun, badan kehakiman atau
penyedia perkhidmatan mereka yang mana Syarikat, anggota gabungannya atau mana-mana pihak ketiga pemproses data diwajibkan untuk
mendedahkan atas permintaan mana-mana undang-undang, undang-undang kecil atau garis panduan. Saya/Kami juga mengakui bahawa
Saya/Kami boleh mendapatkan hak untuk mengetahui maklumat Pemproses Data pihak ketiga atau membetulkan atau menghentikan
pemprosesan DP atau DPS Saya/Kami pada bila-bila masa melalui permintaan bertulis yang menyatakan butiran hubungan Saya/Kami dan
butiran permintaan yang tersebut

IC No. / No Kad Pengenalan ------------------------------------------- ------------------------------------------------------------

Date / Tarikh ------------------------------------------- Signature of Proposer / Tandatangan Pencadang

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.
Bagi menepati Seksyen 16(2) Akta Pengubahan Wang 2001
Saya dengan ini mengesahkan bahawa KP Asal Pencadang/Sijil Pendaftaran Syarikat telah diperiksa dan disahkan ketulenannya oleh saya pada waktu urusniaga.
Third Party verification / Pengesahan Pihak Ketiga :-
IC No. / No. Kad Pengenalan ________________________ Signature /Tandatangan __________________________
Date / Tarikh ________________________ Name / Nama __________________________
“Third Party” means by insurance agents, [ ] To maintain a copy of NRIC for applicants for individual insurance policies with aggregate annual premium exceeding
insurance brokers or staff of insurance RM50,000.00
companies / “Pihak Ketiga” Bermaksud
Ejen Insurans, Broker Insurans atau [ ] To maintain a copy of Business Registration Certificate for companies with aggregate annual premium exceeding RM100,000.00
pekerja disyarikat insurans
PROPOSAL FORM…..(4 of 4)
 Pacific & Orient Insurance Co Bhd
Registration No. 197201000959 (12557-W)
A Member Of The Pacific & Orient Group
SST Registration No. / No. CP : W10-1808-31021805

11 th Floor, Wisma Bumi Raya, No. 10, Jalan Raja Laut, 50350 Kuala Lumpur.
P.O.Box 10953, 50730 Kuala Lumpur. Internet: www.pacific-orient.com / https://www.poi2u.com
Telephone: 03 - 2698 5033 Fax: 03 - 2693 8145 Toll Free: 1 800 88 2121

Invoice / Invois
Invoice No. : 01-01-20-LBF-027158 Date of Invois : 16-09-2020
No. Invois Tarikh Invois

SST Reg. No : Cover Note No. : N/A

No. Pendaftaran CP No. Nota Perlindungan

Agent Code : 32314-01-C Agent Name : KERJAYA POLISI SDN ~

Kod Ejen Nama Ejen

Policy Effective Date : 16-09-2020 Policy Expiry Date : 15-09-2021

Tarikh Polisi Berkuatkuasa Tarikh Polisi Tamat

Policy No. : 01-01-20-LBF-027158 Vehicle No. : WJU9008

No. Polisi No. Kenderaan
Insured Name : SAHROL NIZAM BIN AMAN
Nama Pihak Diinsuranskan
I/C No. : 750720-10-5357 Co. Reg. No. :
No. Kad Pengenalan No. Pendaftaran Perniagaan
Address : DAZA VILLA LOT 9258 JALAN KAMPUNG PEREP~
Alamat 42200 SELANGOR SELANGOR
Description : Payment for Motor Premium
Butiran

Basic Premium / Premium Asas RM 900.62

Trailer Premium / Premium Treler RM
Loading / Caj Tambahan RM 0.00
All Riders / Semua Penunggang RM 0.00
Less NCD / Tolak DTT RM 405.28
Extra Benefits / Manfaat Tambahan RM 0.00
Gross Premium / Premium Kasar RM 495.34
Rebate / Rebat RM 0.00
RM 495.34
Service Tax 6 % / Cukai Perkhidmatan 6% RM 29.72
GST / CBP RM 0.00
Stamp Duty / Duti Setem RM 10.00
Total / Jumlah RM 535.05