TOKIO MARINE INSURANS (MALAYSIA) BERHAD

198601000381 (149520-U)
LEVEL 20, MENARA HAP SENG 3, PLAZA HAP SENG, NO. 1, JALAN P. RAMLEE, 50250 KUALA LUMPUR,
WILAYAH PERSEKUTUAN, MALAYSIA
Tel No. 03-20278200 Fax No. 03-20222295
Website: www.tokiomarine.com

Tell us your experience with

Tokio Marine

The benefit(s) payable under eligible certificate/policy/product is(are) protected by PIDM up to limits. Please refer to PIDM's TIPS Brochure or contact
Tokio Marine Insurans (Malaysia) Berhad or PIDM (visit www.pidm.gov.my).
Manfaat-manfaat yang dibayar di bawah sijil/polisi/produk yang layak adalah dilindungi oleh PIDM sehingga had perlindungan. Sila rujuk Brosur Sistem
Perlindungan Manfaat Takaful dan Insurans PIDM atau hubungi Tokio Marine Insurans (Malaysia) Berhad atau PIDM (layari www.pidm.gov.my).
MOTOR INSURANCE SCHEDULE / JADUAL INSURANS MOTOR
CLASS / POLICY : CA M/CYCLE - ALL RIDERS DATE : 27-04-2024
KELAS / POLISI TARIKH
POLICY NO. / COVER NOTE NO. / V7201104 / VS206760 / CVMTP124 ACCOUNT NO. : WJ-00141330
POLICY WORDING CODE: NO. AKAUN
NO. POLISI / NO. NOTA LINDUNG /
KOD POLISI
AGENT NAME : FIKIRAN BJ
THE INSURED & ADDRESS : SYED ISMADI BIN SYED ABU KASIM NAMA EJEN
PEMILIK & ALAMAT SDN BHD
NO 54
JALAN RUBBER BARAT
KAMPUNG KUDEI LAMA
93400 KUCHING
SARAWAK

PERIOD OF INSURANCE : a. FROM 27-04-2024 (01:37:32PM) TO 26-04-2025 R RM

TEMPOH PERLINDUNGAN DARI HINGGA PREMIUM :
PREMIUM 19.95
(BOTH DATES INCLUSIVE) / (TERMASUK KEDUA-DUA TARIKH)
All Rider : 9.98
b. ANY SUBSEQUENT PERIOD FOR WHICH THE INSURED SHALL PAY LOADING 100.00%:
AND THE COMPANY SHALL AGREE TO ACCEPT A RENEWAL
19.95
PREMIUM NCD 20.00% : 9.98
DISKAUN TANPA TUNTUTAN
MANA-MANA TEMPOH SELANJUTNYA YANG MANA PIHAK (WEF:27-04-2024)
DIINSURANSKAN HENDAKLAH MEMBAYAR DAN SYARIKAT
HENDAKLAH BERSETUJU MENERIMA SATU PREMIUM EXT. PREMIUM : 0.00
PREMIUM TAMBAHAN
PEMBAHARUAN

SERVICE TAX 8.00% : 3.19

CUKAI PERKHIDMATAN 8.00% :
CONTACT NO. / TALIAN UNTUK 0166999129
DIHUBUNGI:

I/C NO. (NEW) / (OLD) : 040216-13-0215 AGE / UMUR : 20 PREMIUM MOTOR : 43.09
NO. KP (BARU) / (LAMA) MOTOR PREMIUM
NATIONALITY : MALAYSIA STAMP DUTY : 10.00
KEWARGANEGARAAN DUTI SETEM
BUSINESS / PROFESSION : OTHERS PREMIUM PA 0.00
PERNIAGAAN / PEKERJAAN PA PREMIUM
BUSINESS REGN NO. : TOTAL PAYABLE: 53.09
NO. PENDAFTARAN SYARIKAT JUMLAH PEMBAYARAN

VEHICLE MAKE MODEL & H.P/CUBIC YEAR OF SEATING CAPACITY INSURED'S ESTIMATE OF VALUE
REGISTRATION TYPE OF BODY CAPACITY/ MANUFACTURE INCLUDING DRIVER INCLUDING ACCESSORIES
NO. MODEL BUATAN DAN TONNAGE OR WATT TAHUN KAPASITI TEMPAT & SPARE PARTS(RM)
NO. PENDAFTARAN JENIS BADAN H.P/KEUPAYAAN ENJIN/ DIPERBUAT DUDUK NILAI ANGGARAN ANDA TERMASUK
KENDERAAN TAN ATAU WATT TERMASUK PEMANDU AKSESORI & ALATGANTIAN(RM)
WPT6262 YAMAHA 114.0 CC 2016 2 0.00
LAGENDA
MOTORCYCLE

ENGINE/MOTOR NO.: CHASSIS NO.:

NO. ENJIN/MOTOR E3S7EE017168 NO. CASIS PMYUE1510G0017186
NAMED DRIVERS : ALL RIDERS
PEMANDU YANG
DINAMAKAN
HIRE PURCHASE - TYPE OF COVER : THIRD PARTY
OWNERS : JENIS PERLINDUNGAN
PEMILIK SEWA BELI
REGISTRATION NA EXCESS : 0.00
CARD NO. : LEBIHAN
NO. KAD PENDAFTARAN
SUBJECT OTHERWISE TO TERMS, EXCEPTIONS AND CONDITIONS OF THE POLICY AND THE ENDORSEMENTS/WARRANTY/MEMORANDUM AS NUMBERED
BELOW:
SELAINNYA TERTAKLUK KEPADA TERMA, PENGECUALIAN DAN SYARAT-SYARAT POLISI INI DAN PENGENDORSAN/WARANTI/MEMORANDUM SEPERTI TERSEBUT DIBAWAH:
(RM) (RM)

Code Description Value Premium

E03P THIRD PARTY ONLY - -
Geographical Area: Malaysia, Republic of Singapore and Negara Brunei Darussalam.
Kawasan Geografi: Malaysia, Republik Singapura dan Negara Brunei Darussalam.
Limitation as to use / Authorised Driver: As described in the Certificate of Insurance.
Had Penggunaan / Pemandu yang diberi kuasa: Seperti yang tercatat dalam Sijil Insuran.

Page 1 27-04-2024 14:55:42

RENEWAL OF POLICY NO.:
PEMBAHARUAN POLISI NO.
DATE OF PROPOSAL & DECLARATION:
TARIKH CADANGAN & PENGISTIHARAN

ISSUED AND SIGNED AT:

DIKELUARKAN DAN DITANDATANGANI KL MARKETING CORP ___________________________________________
ISSUED BY: Chief Executive Officer
DIKELUARKAN OLEH FIKIRAN BJ SDN BHD Ketua Pegawai Eksekutif
TOKIO MARINE INSURANS (MALAYSIA) BERHAD
REFERENCE:
RUJUKAN

Note/Nota:

1. No policy wordings are attached. Kindly download the wordings at www.tokiomarine.com or visit our branch or your servicing agents for the print out.

Tiada butir-butir lengkap polisi disertakan. Anda boleh melayari www.tokiomarine.com atau pergi ke pejabat cawangan atau ejen anda untuk mendapatkan cetakan polisi.

2. If you have any complaints or feedbacks, you may call or write to our Customer Engagement Centre(Complaints Unit) at letusknow@tokiomarine.com.my or 1800 88 0812.

Jika anda mempunyai sebarang aduan atau maklumbalas, slia menghubungi unit aduan kami melalui letusknow@tokiomarine.com.my atau 1800 88 0812.

Page 2 27-04-2024 14:55:42

 TOKIO MARINE INSURANS (MALAYSIA) BERHAD
198601000381 (149520-U)

ROAD TRANSPORT ACT 1987 (MALAYSIA) MOTOR VEHICLE (THIRD PARTY RISKS)
RULES 1959 MALAYSIA MOTOR VEHICLES (THIRD PARTY RISKS & COMPENSATION)
ACT (CAP 189) REPUBLIC OF SINGAPORE MOTOR VEHICLES (THIRD PARTY RISKS & COMPENSATION)
RULES 1960 (REPUBLIC OF SINGAPORE) MOTOR VEHICLES INSURANCE THIRD PARTY
RISKS ACT (CAP 90) NEGARA BRUNEI DARUSSALAM

CERTIFICATE OF INSURANCE
SIJIL INSURANS MY3

POLICY NO. / COVER NOTE NO. V7201104 / VS206760

NO. POLISI / NO. NOTA LINDUNG

1. Index Mark and Registration Number of Vehicle : WPT6262

Tanda Indeks dan No. Pendaftaran Kenderaan

2. Name of Policyholder : SYED ISMADI BIN SYED ABU KASIM

Nama Pemegang Polisi

3. Effective date of the Commencement of Insurance : 27-04-2024

Tarikh Kuatkuasa Tempoh Insurans

4. Date of Expiry of the Insurance : 26-04-2025

Tarikh Tamat Tempoh Insurans

5. Person or Classes of Persons entitled to drive :

Orang atau kelas orang yang layak memandu

(a) The Policyholder.

(b) Any person who is driving on the Policyholder's order or with his permission.

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 tersebut dibenarkan memandu menurut undang-undang perlesenan atau undang-undang atau peraturan untuk memandu
Kenderaan Bermotortersebut atau telah dibenarkan dan tidak dilucutkan kelayakannya atas perintah Mahkamah atau atas sebab mana-mana enakmen
atau peraturan daripada memanduKenderaan Bermotor.

6. Limitations as to use / Had-had Penggunaan:

Use for social domestic and pleasure purposes and by the Policyholder in person in connection with his business
or profession.

The Policy does not cover:

(1) Use for hire or reward.

(2) Use for racing pace-making reliability trial or speed-testing.
(3) Use for the carriage of goods (other than samples) in connection with any trade or business.
(4) Use for any purpose in connection with the Motor Trade

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 Vehicle 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 andCompensation) Act (Cap 189) Republic of Singapore or Section 7 of the Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara
Brunei Darussalam tidak termasukdi bawah tajuk ini.

I / We certify that this covering note 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 Vehicle Insurance (Third Party Risks) Act (Cap 90) Negara
Brunei Darussalam.
Saya/Kami dengan ini mengesahkan bahawa Nota Perlindungan ini yang diperuntukan mengikut Bahagian IV Akta Pengangkutan Jalan 1987 (Malaysia),
Motor Vehicles (Third Party Risks & Compensation) Act (Cap 189) Republic of Singapore and the Motor Vehicle Insurance (Third Party Risks) Act(Cap
90) Negara Brunei Darussalam.

ISSUING DATE / TARIKH DIKELUARKAN : 27-04-2024

AGENCY NO. / NO. AGENCY : WJ-00141330 / FIKIRAN BJ SDN BHD

ISSUED BY / DIKELUARKAN OLEH: FIKIRAN BJ SDN BHD

___________________________________________
Chief Executive Officer / Ketua Pegawai Eksekutif
TOKIO MARINE INSURANS (MALAYSIA) BERHAD

Page 3 27-04-2024 14:55:42

 TOKIO MARINE INSURANS (MALAYSIA) BERHAD
198601000381 (149520-U)
LEVEL 20, MENARA HAP SENG 3, PLAZA HAP SENG, NO. 1, JALAN P. RAMLEE, 50250 KUALA LUMPUR,
WILAYAH PERSEKUTUAN, MALAYSIA
Tel No. 03-20278200 Fax No. 03-20222295
Website: www.tokiomarine.com
SERVICE TAX NUMBER : W10-1808-31013285

INVOICE
INVOIS

E-POLICY NO. : V7201104 (VS206760) INVOICE NO. : B3475322

NO.POLISI NO. INVOIS

ACCOUNT NO. : WJ-00141330 DATE : 27-04-2024

NO. AKAUN TARIKH

THE INSURED : SYED ISMADI BIN SYED ABU KASIM . . .

PIHAK DIINSURANSKAN

ADDRESS : NO 54
ALAMAT JALAN RUBBER BARAT
KAMPUNG KUDEI LAMA
93400 KUCHING
SARAWAK
____________________________________________________________________________________________________________

CLASS OF INSURANCE : MOTORCYCLE-ALL RIDERS

KELAS INSURANS
PERIOD OF INSURANCE : 27-04-2024 TO 26-04-2025
TEMPOH INSURANS
____________________________________________________________________________________________________________
PARTICULARS : : . TOTAL . .
BUTIR-BUTIR JUMLAH
PREMIUM : : RM 39.90 . .
PREMIUM
SERVICE TAX : 8.00% : RM 3.19 . .
CUKAI PERKHIDMATAN
. . : ____________________________________
SUBTOTAL AFTER SERVICE TAX : . RM 43.09 . .
JUMLAH KECIL SELEPAS CUKAI
PERKHIDMATAN
STAMP DUTY : . RM 10.00 . .
DUTI SETEM
. . : ____________________________________
TOTAL PAYABLE : : RM 53.09 . .
JUMLAH PEMBAYARAN

. . : ____________________________________
Note:

1.This policy is subjected to Service Tax under the Service Tax Act 2018 and all Regulations passed by the Government of Malaysia from time to time.
Polisi ini dikenakan Cukai Perkhidmatan di bawah Akta Cukai Perkhidmatan 2018 dan semua Peraturan yang diluluskan oleh Kerajaan Malaysia dari
semasa ke semasa.

____________________________________________________________________________________________________________
.
TOKIO MARINE INSURANS (MALAYSIA) BERHAD
:

_________________________________________
(AUTHORISED SIGNATORY)
(TANDATANGAN PIHAK BERKUASA)

Page 4 27-04-2024 14:55:42

 TOKIO MARINE INSURANS (MALAYSIA) BERHAD
198601000381 (149520-U)
LEVEL 20, MENARA HAP SENG 3, PLAZA HAP SENG, NO. 1, JALAN P. RAMLEE, 50250 KUALA LUMPUR,
WILAYAH PERSEKUTUAN, MALAYSIA
Tel No. 03-20278200 Fax No. 03-20222295
Website: www.tokiomarine.com

Tell us your experience with

Tokio Marine

MOTORCYCLE INSURANCE PROPOSAL FORM

RTD CODE: 91
BORANG CADANGAN INSURANS MOTOSIKAL
IMPORTANT NOTICES
NOTIS PENTING
Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013,
Menurut Perenggan 5 daripada Jadual 9 Akta Perkhidmatan Kewangan 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 the Proposal Form (or when you apply for this insurance). You must answer the questions fully and accurately.
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 di dalam Borang Cadangan (atau semasa memohon insurans 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 di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami.
In addition to answering the questions in the Proposal Form (or when you apply for this insurance), 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 di dalam Borang Cadangan (atau semasa memohon insurans 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 the Proposal Form (or when you
applied for this insurance) 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 (atau
semasa permohonan insurans ini), apa-apa maklumat yang dinyatakan dalam Borang Cadangan tidak tepat atau sudah berubah.

Average Clause / Fasal Purata

It is hereby understood and agreed that if the motor vehicle shall at the time of happening of any loss or damage 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 that this clause shall not apply unless the market value at the time of the loss exceeds the
insured value by 10%.
Adalah difahamkan dan dipersetujui jika kenderaan bermotor semasa berlaku sebarang kejadian atau kerosakan diinsuranskan di bawah harga pasaran, pemilik dikehendaki membayar sendiri semua
perbezaan dan akan menanggung kerugian mengikut kadar kerosakan. Fasal ini tidak perlu diguna pakai melainkan harga pasaran semasa berlaku kerugian melebihi 10% jumlah insuran.

Passenger Liability Cover / Perlindungan Liabiliti Penumpang

It is an offence under the laws of the Republic of Singapore to enter the country without extending passenger liability cover to your motor insurance.
Di bawah Undang-undang Republik Singapura, adalah menjadi satu kesalahan jika memasuki negara tersebut tanpa perlindungan liabiliti ke atas penumpang anda.

(EVERY QUESTION MUST BE ANSWERED. YOU MUST FULLY AND CLEARLY GIVE THE INFORMATION ASKED)
SETIAP SOALAN HARUSLAH DIJAWAB. ANDA PERLU MENGISI DAN MEMBERI INFORMASI YANG DIPERLUKAN DENGAN JELAS

Proposer's name SYED ISMADI BIN SYED ABU KASIM New NRIC 040216-13-0215
Nama Pencadang No. KP Baru

Address NO 54 Telephone No.

Alamat JALAN RUBBER BARAT No. Tel.
KAMPUNG KUDEI LAMA

93400 KUCHING

Old NRIC/Business Regn. No./Passport No. Date of Birth / Age 16-02-2004 / 20

No. KP Lama/No. Pendaftaran Perniagaan/No. Passport Tarikh Lahir / Umur

Marital Status [] Single / [] Married / [] Divorced / [X] Others Gender [X] Male / [] Female Driving Experience Yrs
Taraf Perkahwinan Bujang / Berkahwin / Bercerai / Lain-lain Jantina Lelaki / Perempuan Pengalaman Memandu Thn

Occupation OTHERS Regn. Card No. NA Driving Licence No.

Pekerjaan No. Kad Pendaftaran No. Lesen Memandu

Vehicle Regn. No. WPT6262 Trailer No. Period of Cover From 27-04-2024 To 26-04-2025
No. Pendaftaran Kenderaan No. Treler Tempoh Perlindungan Dari Hingga

Engine/Motor No. E3S7EE017168 Chassis No. PMYUE1510G0017186

No. Injin/Motor No. Casis

Make & Model YAMAHA LAGENDA Seating Capacity 2 cc/tonnage/passenger/watt 114.00 CC

Buatan & Model Tempat Duduk cc/ton/penumpang/watt

Year of Make 2016 Hire Purchase -

Tahun Diperbuat Pinjaman

Type of Cover Comprehensive [] / Third Party [X] / Third Party Fire & Theft [] / Act Only []
Jenis Perlindungan Komprehensif / Pihak Ketiga / Pihak Ketiga Kebakaran & Kecurian / Polisi Akta

Use of Vehicle MOTORCYCLE-ALL RIDERS Sum Insured RM 0.00 Trailer Sum Insured RM 0.00
Kegunaan Kenderaan Jumlah Perlindungan Jumlah Perlindungan Treler

Named Drivers/New NRIC 1. ALL RIDERS 5.

Nama Pemandu/No KP Baru
2. 6.
3. 7.
4. 8.

Additional Benefits -
Perlindungan Tambahan
(Subject to additional premium)
(Tertakluk kepada tambahan premium)

Class of Vehicle M/CYCLE - ALL RIDERS

Kelas Kenderaan

Please indicate where the vehicle is usually parked when not in use
Sila nyatakan dimana kenderaan anda kerap diletakkan jika tidak digunakan

[] Locked Garage [] Unlocked Garage [X] Locked Compound [] Unlocked Compound

Garaj Berkunci Garaj Tidak Berkunci Kawasan Halaman Berkunci Kawasan Halaman Tidak Berkunci

[] Open Public Car Park [] Secure Public Car Park [] Public Road
Kereta Awam Terbuka Dengan Fungsi Keselamatan Jalan Awam

Please indicate Local/Imported vehicle:

Page 5 27-04-2024 14:55:42

Nyatakan kenderaan tempatan/import:

[] Locally Assembled (Local Manufacturer, eg: Proton, Perodua)

Pemasangan Tempatan (Pengeluar Tempatan, contoh: Proton, Perodua)

[] CKD (Complete Knock Down)

CKD (Kenderaan Import Baru)

[] CBU (Complete Built Up) - New

CBU (Kenderaan Import Baru)

[] CBU (Complete Built Up) - Used (Recon)

CBU (Kenderaan Import Terpakai)

Please declare any modifications to the vehicle Yes / No

Sila nyatakan sebarang pengubahsuaian ke atas kenderaan Ya / Tidak
If yes, please give full details/ Sekiranya ya, sila nyatakan butiran lengkap
..............................................................................................................................................................................................................................................................................

Do you suffer from any physical/mental illness Yes / No

Adakah anda mengalami kecacatan fizikal/mental Ya / Tidak
If yes, please give full details/ Sekiranya ya, sila nyatakan butiran lengkap
..............................................................................................................................................................................................................................................................................

Have you been involved in any motor accident or made any claims during the past (3) years? Yes / No
Pernahkah anda terlibat dalam kemalangan atau membuat tuntutan sepanjang tiga tahun yang lepas? Ya / Tidak
If yes, please give full details of previous insurer(s) and the accident(s).
Sekiranya ya, sila nyatakan butiran lengkap pengisurans terdahulu dan kemalangan.

..............................................................................................................................................................................................................................................................................
Kindly list out other current/proposed insurance covers taken or to be taken with our Company
Sila nyatakan lain-lain perlindungan insurans yang telah diambil atau akan diambil dengan syarikat kami
..............................................................................................................................................................................................................................................................................

Apply To Comprehensive Cover

Compulsory Excess/Lebihan Wajib:
Cubic Capacity of EngineabcdefgExcess/Lebihan
100 c.c and belowabcdefghijklmn RM75.00
101 c.c to 150 c.cabcdefghijklmnoRM100.00
151 c.c to 250 c.cabcdefghijklmnoRM150.00
250 c.c to 500 c.cabcdefghijklmno1% of sum insured subject to a maximum of RM500.00
Over 500 c.cabcdefghijklmnopqrs2.5% of sum insured subject to a maximum of RM1,000.00

Payment Instructions
Arahan Pembayaran

[ ] I enclose a cheque/bank draft/money order

Saya sertakan cek/bank draf/kiriman wang pos (No. ..........................................................................................)
If paying by credit card
Jika membayar dengan kad kredit
[ ] Paying with credit card [ ] Mastercard [ ] Visa
Bayar dengan kad kredit
Name of Cardholder
Name Pemegang Kad _________________________________________________________________
Card Number |__|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__| Expiry Date |__|__|__|__|
MMMMMYMYM
Nombor Kad Tarikh luput
Amount: payable to
Jumlah: RM .................................... bayar kepada TOKIO MARINE INSURANS (MALAYSIA) BERHAD
(inclusive of RM10 stamp duty and is subjected to Service Tax under the Service Tax Act 2018 and all Regulations passed by the Government of
Malaysia from time to time
termasuk duti setem RM10 dan Cukai Perkhidmatan di bawah Akta Cukai Perkhidmatan 2018 dan semua Peraturan yang diluluskan oleh Kerajaan
Malaysia dari semasa ke semasa)

_______________________ _______________________
Signature of Cardholder Date / Tarikh
Tandatangan Pemegang kad
Acknowledgement & Declaration
Perakuan & Pengisytiharan
Personal Data Protection Act 2010 (PDPA) Notice/Notis Akta Perlindungan Data Peribadi 2010

I/We acknowledge and consent that the personal data, including any sensitive personal data, collected herein be used, processed and disclosed for the
purpose of this proposal to reinsurers; individuals or organizations associated with Tokio Marine Group, or any selected third party (within or outside
Malaysia). I/We acknowledge that I/we am/are obligated to provide the above personal data failing which my/our proposal could not be processed and
that I/we am/are entitled to obtain access to, request for correction of or limit the processing of my/our personal data; and
Saya/Kami mengakui dan bersetuju bahawa data peribadi, termasuk apa-apa data peribadi yang sensitif, yang dikumpulkan di sini digunakan, diproses
dan dizahirkan untuk tujuan cadangan ini kepada penanggung insurans semula; individu atau organisasi yang berkaitan dengan Kumpulan Tokio
Marine, atau sebarang pihak ketiga (di dalam atau di luar Malaysia). Saya/Kami mengakui bahawa saya/kami perlu memberikan data peribadi di atas,
dan jika gagal berbuat demikian, cadangan saya/kami tidak dapat diproses dan saya/kami berhak untuk mendapatkan akses kepada, meminta
pembetulan atau mengehadkan pemprosesan data peribadi saya/kami; dan

Page 6 27-04-2024 14:55:42

[ ] I/We further agree that you may disclose and share my/our information with individuals or organizations associated with Tokio Marine Group,
strategic partners and other third parties (within or outside Malaysia) as the Company deems fit for the purpose of cross-selling, promoting and
marketing financial products and services offered by you and the other entities.
Saya/Kami juga bersetuju bahawa anda boleh mendedahkan dan berkongsi maklumat saya/kami dengan individu atau organisasi yang
berkaitan dengan Kumpulan Tokio Marine, rakan strategik dan pihak ketiga lain (di dalam atau di luar Malaysia) yang difikirkan patut untuk
tujuan jualan silang, promosi dan pemasaran produk dan perkhidmatan kewangan yang ditawarkan anda dan entiti-entiti lain.
Protection of your privacy is very important to us. Please visit our website at "www.tokiomarine.com" to view our Privacy Statement.
Perlindungan privasi anda adalah sangat penting bagi kami. Sila layari laman web kami di "www.tokiomarine.com" untuk melihat Penyata Privasi kami.

Declaration
Pengisytiharan

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

_______________________ _______________________
Signature of Proposer Date/Tarikh
Tandatangan Pemohon Insurans

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Verification of Applicant's Identification
Pengesahan Identiti Pemohon
To be completed by Insurance Agents, Insurance Brokers or Staff of TMIM.
Untuk dilengkapkan oleh Ejen Insurans, Broker Insurans atau Kakitangan TMIM.

1. In compliance with the Anti-Money Laundering, Anti-Terrorism Financing and Proceeds of Unlawful Activities Act 2001, I hereby certify that the
Applicant's original NRIC/Passport/Business Registration Certificate* was verified and authenticated by me at the point of sales.
Selaras dengan Akta Pencegahan Pengubahan Wang Haram, Pencegahan Pembiayaan Keganasan dan Hasil daripada Aktiviti Haram 2001,
saya dengan ini mengesahkan bahawa Kad Pengenalan/Pasport/Sijil Pendaftaran Perniagaan* asal Pemohon telah disemak dan disahkan oleh
saya semasa urusniaga dijalankan.

2. Photocopy of the Applicant's original NRIC/Passport/Business Registration Certificate* is attached to this proposal form, which premium exceeds
RM50,000 per transaction for single policy or exceeds RM100,000 per transaction for group policy.
Salinan Kad Pengenalan/Pasport/Sijil Pendaftaran Perniagaan* asal Pemohon disertakan bersama borang cadangan ini, di mana premium
polisi tunggal melebihi RM50,000 setiap transaksi atau premium polisi kumpulan melebihi RM100,000 setiap transaksi.

*Please delete where not applicable.

Sila potong mana yang tidak berkenaan.

Signature/Tandatangan:
Name/Nama:
IC No./No. Kad Pengenalan:
Date/Tarikh:

Application for Purchase of Group Insurance Policy / Digunapakai untuk Pembelian Polisi Insurans Kumpulan
I/We (who purchase the group insurance policy) hereby confirm that I/we have signed the original copy of the NRIC /Passport/Business Registration
Certificate* and verified the details of the persons covered under the group policy.
Saya/Kami (yang membeli polisi insurans kumpulan) dengan ini mengesahkan bahawa saya/kami telah menyemak Kad Pengenalan/Pasport/Sijil
Pendaftaran Perniagaan* yang asal dan mengesahkan butiran orang yang dilindungi di bawah polisi kumpulan.

*Please delete where not applicable.

Sila potong mana yang tidak berkenaan.

Signature/Tandatangan:
Name/Nama:
IC No./No. Kad Pengenalan:
Date/Tarikh:

Tokio Marine Insurans (Malaysia) Berhad is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia
Tokio Marine Insurans (Malaysia) Berhad dilesenkan di bawah Akta Perkhidmatan Kewangan 2013 dan dikawalselia oleh Bank Negara Malaysia

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