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MCIS ZURICH INSURANCE BERHAD (Co. No: 435318-U) Wisma MCIS Zurich, Level 3A, Tower 2, Jalan Barat, 46200 Petaling Jaya, Selangor. Malaysia Customer Contact Center : (603) 7955 2577 Tel : (603) 7955 2577 Fax : (603) 7957 1562 ' MOTOR INSURANCE PROPOSAL FORM BORONG CADANGAN INURAN OTOR ref no. : Q13038463 page 2 of 3 Statement Pursuant to Section 149(4) of the Insurance Act 1996 - You are disclose in this Proposal Form Fully and faithfully, all the facts which you ought to know or in the circumstances could be expected to know to be relevant otherwise policy issued hereunder may be void. Section 141(1) of the Insurance Act 1996 - No cover can be granted until premium has been paid in accordance with the Regulations issued under this section. Any person who fails to comply with the Section shall be guilty of an offence and shall on conviction be liable o f a fine not exceeding RM500,00. Where payment of the premium is made by cheque, money order, postal order, bank draft or cashier order the payment mu st be crossed "Account Payee Only" and made in favor of the Insurer. Average Clause - If your Vehicle shall at the time of happening of any loss and damage (be it partial/total) be insured for a sum less 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 l oss accordingly, provided always that this shall not apply unless the market value at the time of loss exceeds the insured value by 10% Passenger Liability Cover - 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. Mengikut Seksyen 149(4) Akta Insurans, 1996 - anda dikehendaki menyatakan dengan penuh dan benar butir-butir yang diminta di dalam borang cadangan ini, jika tidak polisi yang dikeluarkan mungkin tidak sah. Seksyen 141(1) Akta Insurans 1996 - Tiada perlindungan akan diberikan sehingga premium dibayar mengikut undang-undang di bawah seksyen ini. Barangsiapa yang gagal mematuhi seksyen ini akan dianggap melakukan kesalahan dan jika dipersalahkan akan dikenakan denda tidak melebihi RM500,0 00.Dimana premium dibayar melalui Cek, Kiriman Wang, Kiriman Pos, Deraf Bank atau Perintah Juruwang, pembayaran hendaklah berpalang "Akaun Penerima Sahaja". Fasal Purata - Jika pada masa berlakunya kehilangan/kemalangan (samada kerosakan sedikit atau teruk), kenderaan anda dilindungi untuk jumlah k ekurangan daripada nilai sepatutnya (dimana ia melebihi 10% daripada nilai pasaran) anda dianggap penagung insurans sendiri bagi jumlah yang meleb ihi dan akan menanggung sendiri purata jumlah yang tidak dilindungi. Perlindungan Tanggungan Kepada Penumpang - Adalah merupakan satu kesalahan di bawah undang-undang di Republik Singapura, jika memasuki negara tersebut tanpa mengambil tanggungan kepada penumpang. THE PROPOSER/ BUTIR PENCADANG : LEE SENG KEAT - NAME OF THE INSURED Biz Reg. No./ No. Daftar Perniagaan Other Identity No./ No. Lain-Lain New IC No/ IC No Baru 800517-03-5456 Passport No/ Others No Old IC No/ IC No Lama . Date of Birth/ Tarikh Lahir 17 MAY 1980 Gender/ Jantina FEMALE Marital Status/ Taraf Perkahwinan SINGLE Nationality/ Kewarganegaraan MALAYSIA Race/ Bangsa CHINESE Occupation/ Jawatan TEACHER - PROFESSIONALS Address/ Alamat 154-6-17,BUKIT GEMBIRA CONDO, JALAN RIANG, OFF JALAN KUCHAI LAMA, Tel No./ No. Tel 0166152626(M), SCOPE OF COVER/PERLINDUNGAN - PRIVATE CAR FOR PRIVATE USE - COMPREHENSIVE Period of Insurance/ Tempoh Insurance 17 SEP 2013 12:01 AM to/ hingga 16 SEP 2014 11:59 PM HP Company/ Syarikat Pinjaman NIL Type of Good Carried/ Jenis Barang Yang Dibawa Private Car for private use DESCRIPTION OF VEHICLE NO./ BUTIR-BUTIR KENDERAAN NO. - WUJ6467 Sum Insured/ Jumlah Diinsuranskan 26,000.00 Make & Model/ Buatan & Model PROTON SAGA 1.3(A) Excess/ Lebihan 260.00 Engine No./ No.Enjin S4PEQM3786 Year of Make/ Tahun Dibuat 2010 Chassis No./ No.Casis PL1BT3SRRAB172193 Seating Capacity/ Muatan Tempat Duduk 5 Cubic Capacity/ Kuasa Injin 1332 CC Log Book No./ No. Buku Log 0015184 Vehicle Body/ Badan Kenderaan SALOON Security/Garage/ Keselamatan/Garaj WITHIN COMPOUND OF RESIDENCE Safety Features/ Ciri-ciri Keselamatan NONE Anti-theif device/ Alat Pencegah Kecurian WITHOUT MEC. DEV. - FACTORY FITTED ALAM PERMITTED DRIVERS / PEMANDU YANG DIBENARKAN EXTENDED COVERS / PERLINDUNGAN TAMBAHAN - 1. WINDSCREEN SUM INSURED: 300.00 Date Issued/ Tarikh Dikeluarkan : 16 SEP 2013 09:49:48PM Issued by/ Dikeluarkan Oleh : 090299 Transaction Type/ Jenis Transaksi : NWOO - New Business - Old Vehicle, Old Registration Agent No/ No.Ajen : ZM2000740 Agent Contact/ No.Ajen Untuk Dihubungi: Tel:012-217 3589 Fax:03-8076 4384 Page 216-09-2013 21:49:52
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