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PENGECUALIANKeadaan sedia ada, kehamilan, bunuh diri, peperangan, melahirkan anak atau keguguran dan kerugian diakibatkan ketika kenderaan digunakan untuk perlumbaan, ujian kelajuan, sewa, perlumbaan rali jalanraya atau semasa pemandu di bawah pengaruh alkohol atau dadah atau memandu tanpa lesen sah.
NOTIS PENTING1. Borang cadangan ini hanya ringkasan saja. Maklumat terperinci
tentang perlindungan polisi boleh didapati di dalam polisi.
2. Menurut Akta Perkhidmatan Kewangan 2013, Seksyen 129, Jadual 9, Perenggan 5: Adalah menjadi kewajipan pengguna untuk mengambil penjagaan munasabah untuk tidak membuat salah nyataan kepada penanggung insurans berlesen semasa menjawab apa-apa soalan yang diperlukan yang berkaitan dengan keputusan penanggung insurans sama ada untuk menerima atau tidak risiko dan kadar dan terma yang hendak dipakai.
3. Liabiliti adalah tidak ditanggung sehingga cadangan ini diterima oleh Syarikat.
4. Sebarang pertukaran informasi yang telah diberi mesti dilaporkan kepada Syarikat serta merta; jika tidak, Syarikat berhak menolak sebarang liabiliti.
5. Sila berikan jawapan yang tepat kepada setiap soalan; tanda sengkang adalah tidak memadai.
6. Lampiran Pemberitahuan Produk boleh didapati daripada laman web www.kurnia.com. Anda dinasihatkan untuk membaca Lampiran Pemberitahuan Produk sebelum anda memutuskan untuk mengambil mana-mana produk.
7. Pemegang Polisi adalah dinasihatkan untuk membuat penamaan di bawah Seksyen 130, Akta Perkhidmatan Kewangan 2013 dan boleh mendapatkan Borang Penamaan dari Ibu Pejabat, Cawangan atau Ejen kami.
8. AmGeneral Insurance Berhad dilesenkan di bawah Akta Perkhidmatan Kewangan 2013 dan dikawal selia oleh Bank Negara Malaysia.
9. Versi lengkap Notis Privasi AmGeneral Insurance Berhad boleh didapati di laman web kami di www.amgeneralinsurance.com untuk rujukan lanjut anda.
10. Sekiranya berlaku konflik atau percanggahan berhubung peruntukan teks Bahasa Inggeris dengan mana-mana Dokumen Kontrak dan apa-apa terjemahannya, maka teks Bahasa Inggeris akan diguna pakai.
EXCLUSIONSPre-existing conditions, pregnancy, suicide, war risks, childbirth or miscarriage and losses incurred while the vehicle is used for racing, speed-testing, hire, road rally or whilst the driver is under the influence of alcohol or drugs or driving without a valid licence.
IMPORTANT NOTICE 1. This proposal form is a brief description only. The full details of the
policy coverage are to be found in the policy.
2. Statement pursuant to Financial Services Act 2013, Section 129, Schedule 9, Para 5: It is the duty of the customer to take reasonable care not to make a misrepresentation to the licensed insurer when answering any question which the insurer may request that are relevant to the decision of the insurer whether to accept the risk or not and rates and terms to be applied.
3. Liability does not attach until the proposal has been accepted by the Company.
4. Any changes in the information given must be reported to the Company immediately; otherwise, the Company may reserve the right to decline all liability.
5. Please give a definite answer to each question; dashes are not sufficient.
6. Product Disclosure Sheet (PDS) can be obtained from our website www.kurnia.com. You are advised to read the PDS before you take out any product.
7. Policy Owners are advised to make a nomination pursuant to Section 130 of the Financial Services Act 2013 and can obtain a Nomination Form from our service counters at our Head Office, Branches or Agents.
8. AmGeneral Insurance Berhad is licensed under Financial Services Act 2013 and regulated by Bank Negara Malaysia.
9. A full version of the Privacy Notice of AmGeneral Insurance Berhad is available on our website at www.amgeneralinsurance.com for your further reference.
10. In the event of a conflict or discrepancy between the provisions of the English text of any of the Contract Documents and any translations thereof, the English text shall prevail.
TABLE OF BENEFITS / JADUAL FAEDAH
Item /Perkara Benefits / Faedah
Note : Premium stated are inclusive of 6% Service Tax. / Nota: Premium yang tertera adalah termasuk 6% Cukai Perkhidmatan.
Plan / Pelan A
Plan / Pelan 88
Sum Insured / Jumlah Diinsuranskan (RM)
Plan / Pelan B
Medical Expenses (per person) / Perbelanjaan Perubatan (setiap orang)
Corrective Dental and/or Cosmetic Surgery (per person) / Pembedahan Pembetulan Gigi dan/atau Pembedahan Kosmetik (setiap orang)
Ambulance Fees (per person) / Yuran Ambulan (setiap orang)
32,000 peraccident /
setiap kemalangan
1,500 peraccident /
setiap kemalangan
3,000 peraccident /
setiap kemalangan
4,000 peraccident /
setiap kemalangan
Taxi and Car Rental Expenses / Perbelanjaan Sewa Teksi dan Keretai. Taxi Expenses / Perbelanjaan Teksi ii. Car Rental Expenses up to RM150 per day / Perbelanjaan Sewa Kereta sehingga RM150 sehari(Maximum per incident and limited to 3 reimbursements a year) / (Maksimum setiap kejadian dan bayaran balik terhad kepada 3 kali setahun)
12Taxi / Teksi - 60
Car Rental / Sewa Kereta - 400
Not applicable / Tidak berkenaan
Taxi / Teksi - 60Car Rental /
Sewa Kereta - 400
Taxi / Teksi - 60Car Rental /
Sewa Kereta - 400
Referral Assistance Program Within Malaysia - Taxi and Car Rental Assistance, Arrangement for Hotel Accommodation, Arrangement for Emergency Evacuation, Referral to Service Centre and Car Rental Company and Emergency Message Transmission / Program Bantuan Rujukan Di Dalam Malaysia - Bantuan Sewa Teksi dan Kereta, Pengurusan untuk Penginapan Hotel, Pengurusan untuk Pemindahan Kecemasan, Rujukan ke Pusat Servis dan Syarikat Sewa Kereta dan Penghantaran Pesanan/Mesej Kecemasan
15 Included / TermasukNot applicable / Tidak berkenaan
Included / Termasuk
Included / Termasuk
Compassionate Flood Expenses (any one incident/in aggregate any one period of insurance) / Perbelanjaan Ehsan Akibat Banjir (maksimum setiap kejadian/agregat bagi setiap tempoh insurans)6 1,5001,500 1,500 1,500
Compassionate Allowance for Vehicle Total Loss due to Vehicle Collision or Theft / Elaun Ehsan Bagi Kerugian Penuh/Menyeluruh Kenderaan Akibat Perlanggaran Atau Kecurian KenderaanPays an amount equivalent to 10% of Named Vehicle’s Motor Comprehensive or Third Party, Fire and Theft Sum Insured and benefit is only payable if the Motor Comprehensive or Third Party, Fire and Theft Policy is insured with AmGeneral (maximum per incident) / Membayar nilai bersamaan 10% daripada Jumlah Diinsuranskan ke atas Polisi Motor Komprehensif atau Pihak Ketiga, Kebakaran dan Kecurian bagi Kenderaan yang Dinamakan dan faedah akan dibayar jika Polisi Motor Komprehensif atau Pihak Ketiga, Kebakaran dan Kecurian diinsuranskan dengan AmGeneral (maksimum setiap kejadian)
11 8,0006,000 12,000 18,000
Car Loan Protection / Perlindungan Pinjaman Kereta17 5,0005,000 5,000 5,000
Compassionate Cover For Smash And Grab / Perlindungan Ehsan untuk Samun dan Pecah Tingkapi. Window and/or Windscreen Broken / Tingkap dan/atau Cermin Kereta Pecahii. Loss or Damage to Personal Effects and/or Loss of Cash / Kehilangan atau Kerosakan Barangan Peribadi dan/atau Kehilangan Wang Tunai
16 1,000500
1,000500
1,000500
1,000500
Vehicle Breakdown Assistance and Towing Service Within Malaysia (per incident) - Including Unlimited Toll Charges incurred / Perkhidmatan Bantuan Kerosakan Kenderaan dan Perkhidmatan Tunda Di Dalam Malaysia (setiap kejadian) - Termasuk Caj Tol Tanpa Had9
Unlimited distance / Tiada
had jarak
Up to 600 km roundtrip /
sehingga 600km pergi balik
Unlimited distance / Tiada
had jarak
Unlimited distance / Tiada
had jarak
Plan / Pelan C
Accidental Death (per person) / Kematian Akibat Kemalangan (setiap orang)1 30,00015,000 75,000 120,000
Permanent Disablement (per person) / Hilang Upaya Kekal (setiap orang)2 30,00015,000 75,000 120,000
Hospital Income (per person, up to maximum 60 days per year) / Pendapatan Hospital (sehingga maksimum 60 hari setiap tahun setiap orang)4 50 per day / sehari30 per day /
sehari75 per day /
sehari100 per day
/ sehari
Bereavement Allowance (per person) / Elaun Pengebumian (setiap orang)Sum Insured doubled if Insured suffers death due to Ebola, SARS, Japanese Encephalitis, Chikungunya, Malaria and Dengue (provided it is not a declared pandemic in Malaysia) / Jumlah Diinsuranskan berganda jika Pihak Diinsuranskan meninggal dunia akibat Ebola, SARS, Ensefalitis Jepun, Chikungunya, Malaria dan Denggi (dengan syarat ia bukan wabak yang diisytiharkan di Malaysia)
5 750750 750 750
Car Replacement Expenses (up to RM150 per day, maximum per incident) / Perbelanjaan Gantian Kereta (sehingga RM150 sehari, maksimum setiap kejadian)10 600450 750 900
Hotel Accommodation Expenses for vehicle breakdown in Malaysia up to RM150 per night (maximum per incident and limited to 3 reimbursements a year) / Perbelanjaan Penginapan Hotel bagi Kerosakan Kenderaan di Malaysia sehingga RM150 semalam (maksimum setiap kejadian dan bayaran balik terhad kepada 3 kali setahun)13 400
Not applicable / Tidak berkenaan 400 400
Hotel Accommodation Expenses for Vehicle Breakdown in Singapore up to RM150 per night (maximum per incident and limited to 3 reimbursements a year) / Perbelanjaan Penginapan Hotel bagi Kerosakan Kenderaan di Singapura sehingga RM150 semalam (maksimum setiap kejadian dan bayaran balik terhad kepada 3 kali setahun)14 300
Not applicable / Tidak berkenaan 300 300
Outstanding Credit Card Balance (applicable for Insured only, up to maximum) / Baki Kad Kredit Tertunggak (untuk Pihak Diinsuranskan sahaja, sehingga maksimum) 7 500300 1,000 1,500
Double Indemnity During A National Public Holiday in Malaysia (per person) / Indemniti Berganda Ketika Cuti Umum Seluruh Malaysia (setiap orang)8 60,00030,000 150,000 240,000
Private Vehicle / Kenderaan Persendirian
A Driver and up to 4 passengers / Seorang Pemandu dan sehingga 4 penumpang
Each additional passenger / Setiap penumpang tambahan
88.00
8.48
137.80
12.72
243.80
24.38
349.80
37.10
Annual Premium / Premium Tahunan (RM)(RM) (RM) (RM)
UW-NM-F415
car loanprotection
smash andgrab cover
PERFECT RIDER PLUS
Drive with peace of mind, for only RM88 p.a.Dengan hanya RM88 setahun, kini anda boleh pandu dengan tenang
An AmBank Group brand
1-800-88-6333 www.kurnia.comVisit our agents & branches
An AmBank Group brand
www.kurnia.comKunjungi ejen & cawangan kami 1-800-88-6333
0719
Menara Shell, No. 211, Jalan Tun Sambanthan,50470 Kuala Lumpur, Malaysia.P.O. Box 11228, GPO Kuala Lumpur,50740 W.P. Kuala Lumpur, Malaysia.Tel : 1-800-88-6333Email : [email protected] Web : www.kurnia.com (Service Tax Registration No.: B16-1808-31015443)
Lot 105 to 109,1st �oor, Crown Square,88, Jalan Pending,93450 Kuching, SarawakTel: 082-339 171Fax: 082-339 176
PERFECT RIDER PLUS PERFECT RIDER PLUSRoad accidents can happen anytime. Let PERFECT RIDER PLUS take care of your worries. While you are out driving or riding, boarding or alighting from the named vehicle, rest assured both driver and passengers are protected.
Unique Features
• Affordable premium for as low as RM88 per year.
• 24 hours Vehicle Breakdown Assistance and Towing Service within Malaysia including Unlimited Toll Charges. For Assistance to contact 24 hours toll free number 1-800-88-6333.
• Children enjoy the same limit as adult on applicable benefits.
• Double Indemnity during a national public holiday in Malaysia.
• Bereavement Allowance - Sum Insured doubled if Insured (Policyholder) suffers death due to Ebola, SARS, Japanese Encephalitis, Chikungunya, Malaria and Dengue.
• Compassionate Allowance for Vehicle Total Loss due to Vehicle Collision or Theft (covered if Named Vehicle’s Motor Comprehensive or Third Party, Fire and Theft Insurance is insured with AmGeneral).
• Compassionate Flood Expenses.
• Compassionate Cover For Smash And Grab.
• Car Loan Protection.
Kemalangan jalan raya boleh berlaku pada bila-bila masa. Pilihlah PERFECT RIDER PLUS untuk menjaga kebimbangan anda. Semasa anda memandu atau menumpang, menaiki atau turun dari kenderaan yang dinamakan, yakinlah kedua-dua pemandu dan penumpang dilindungi.
Ciri-Ciri Unik
• Premium serendah RM88 setahun.
• 24 Jam Perkhidmatan Bantuan Kerosakan Kenderaan dan Perkhidmatan Tunda di dalam Malaysia, termasuk Caj Tol Tanpa Had. Panggilan ke talian bebas tol bernombor 1-800-88-6333 untuk Khidmat Bantuan.
• Kanak-Kanak menikmati had faedah sama seperti had faedah orang dewasa untuk faedah tertentu.
• Indemniti Berganda ketika cuti umum seluruh Malaysia.
• Elaun Pengebumian - Jumlah Diinsuranskan berganda jika Pihak Diinsuranskan (Pemegang Polisi) meninggal dunia akibat Ebola, SARS, Ensefalitis Jepun, Chikungunya, Malaria dan Denggi.
• Elaun Ehsan bagi Kerugian Penuh/Menyeluruh Kenderaan Akibat Perlanggaran atau Kecurian Kenderaan (dilindungi jika Polisi Motor Komprehensif atau Pihak Ketiga, Kebakaran dan Kecurian Kereta Dinamakan diinsuranskan dengan AmGeneral).
• Perbelanjaan Ehsan Akibat Banjir.
• Perlindungan Ehsan untuk Samun dan Pecah Tingkap.
• Perlindungan Pinjaman Kereta.
Eligibility
• Private Vehicle Owners aged 17 years and above.
Kelayakan
• Pemilik Kereta Persendirian berumur 17 tahun dan ke atas.
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here
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re to
ans
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all t
he q
uest
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her
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hone
stly
and
to th
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st o
f My/
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kno
wle
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colle
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r a c
ontin
uous
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rm th
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nge,
am
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ent o
r add
ition
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tions
unt
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licy
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issu
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nd co
mes
into
effe
ct. I/
We
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nd th
at th
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ay v
oid
the
polic
y an
d re
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n th
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f a d
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erat
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mis
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riptio
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rror
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r non
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ct (w
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r not
ther
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as a
n in
quiry
/que
stio
n ra
ised
per
tain
ing
to th
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me)
with
or w
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t an
inte
ntio
n to
def
raud
the
Com
pany
by
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Us
whi
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ould
hav
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m p
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acc
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nce
of th
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k by
the
Com
pany
. / S
aya/
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i men
gesa
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awa
saya
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ah m
embe
ri se
penu
h pe
rhat
ian
untu
k m
enja
wab
kes
emua
soal
an y
ang
terk
andu
ng se
cara
juju
r di
sepa
njan
g pe
nget
ahua
n, k
eper
caya
an d
an in
gata
n Sa
ya/K
ami,
dan
Saya
/Kam
i aka
n be
rtan
ggun
gjaw
ab u
ntuk
mem
berit
ahu
piha
k Sy
arik
at b
erke
naan
seba
rang
pe
ruba
han,
pin
daan
ata
u pe
nam
baha
n pa
da so
alan
di a
tas s
ehin
gga
Polis
i dik
elua
rkan
dan
ber
kuat
kuas
a. S
aya/
Kam
i fah
am b
ahaw
a Sy
arik
at b
oleh
mem
bata
lkan
Po
lisi i
ni d
an m
enol
ak se
bara
ng tu
ntut
an (s
ama
ada
kese
luru
han
atau
seba
hagi
an) s
ekira
nya
berla
ku sa
lah
nyat
a, p
ener
anga
n ya
ng sa
lah,
kes
ilapa
n, te
rtin
ggal
ata
u tid
ak m
ende
dahk
an fa
kta
(sam
a ad
a te
rdap
at p
erta
nyaa
n/pe
rsoa
lan
atau
pun
tidak
dik
emuk
akan
men
gena
i yan
g sa
ma)
den
gan
niat
ata
u ta
npa
niat
unt
uk m
enip
u Sy
arik
at o
leh
Saya
/Kam
i yan
g ak
an m
enje
jask
an p
rem
ium
yang
per
lu d
ibay
ar a
tau
terh
adap
pen
erim
aan
risik
o ol
eh p
ihak
Sya
rikat
.I/W
e ag
ree
that
the
Com
pany
sha
ll ha
ve t
he r
ight
to u
se M
y/O
ur d
ata
and
pers
onal
info
rmat
ion
for t
he p
urpo
se o
f the
insu
ranc
e op
erat
iona
l pro
cess
whi
ch
mig
ht in
clud
e tr
ansf
er o
f dat
a an
d pe
rson
al in
form
atio
n to
the
Com
pany
’s re
late
d co
mpa
nies
, sub
sidi
arie
s an
d/or
its
hold
ing
com
pany
, out
sour
cing
par
tner
s, re
insu
rers
and
sol
icito
r but
not
lim
ited
to a
ffilia
te c
ompa
nies
incl
udin
g th
eir o
utso
urci
ng p
artn
ers.
/ Say
a/Ka
mi b
erse
tuju
bah
awa
piha
k Sy
arik
at b
erha
k un
tuk
men
ggun
akan
dat
a da
n m
aklu
mat
per
ibad
i say
a/ka
mi b
agi t
ujua
n pe
mpr
oses
an o
pera
si in
sura
ns y
ang
mun
gkin
term
asuk
pem
inda
han
data
dan
mak
lum
at
perib
adi k
epad
a Sy
arik
at ya
ng se
kutu
den
gan
piha
k Sy
arik
at, a
nak-
anak
syar
ikat
dan
/ata
u sy
arik
at in
dukn
ya, r
akan
kong
si p
embe
kala
n lu
ar, P
enan
ggun
g In
sura
ns
Sem
ula
dan
pegu
am ca
ra te
tapi
tida
k te
rhad
kep
ada
syar
ikat
-sya
rikat
seku
tu te
rmas
uk ra
kan
kong
si p
embe
kala
n lu
ar m
erek
a.I/W
e fu
rthe
r ag
ree
that
the
Com
pany
, its
par
tner
s an
d its
rel
ated
com
pani
es, s
ubsi
diar
ies
and/
or it
s ho
ldin
g co
mpa
ny c
an s
hare
and
use
My/
Our
dat
a an
d pe
rson
al in
form
atio
n fo
r the
pur
pose
of p
rom
otin
g th
e Co
mpa
ny’s
and
its re
late
d co
mpa
nies
’, sub
sidi
arie
s’ an
d/or
its
hold
ing
com
pany
’s pr
oduc
t, ne
w s
ervi
ces
and
supp
ort r
equi
rem
ents
, and
mar
ketin
g ca
mpa
igns
and
act
iviti
es a
nd c
omm
erci
al tr
ansa
ctio
ns. /
Say
a/Ka
mi s
eter
usny
a be
rset
uju
baha
wa
piha
k Sy
arik
at, r
akan
ni
agan
ya d
an sy
arik
at-s
yarik
at se
kutu
, ana
k-an
ak sy
arik
at d
an/a
tau
syar
ikat
indu
k be
rhak
unt
uk b
erko
ngsi
dan
men
ggun
akan
dat
a da
n m
aklu
mat
per
ibad
i unt
uk
tuju
an m
empr
omos
ikan
pro
duk,
per
khid
mat
an b
aru
dan
kepe
rluan
soko
ngan
, dan
kem
pen
dan
aktiv
iti p
emas
aran
dan
tran
saks
i kom
ersi
l yan
g di
kend
alik
an o
leh
piha
k Sy
arik
at d
an sy
arik
at se
kutu
, ana
k-an
ak sy
arik
at d
an/a
tau
syar
ikat
indu
k.
/
/
/
/
Dat
eTa
rikh
Sign
atur
e of
Pro
pose
r / T
anda
tang
an P
enca
dang
Yes
/ Ya
N
o / T
idak
Yes
/ Ya
N
o / T
idak
Yes
/ Ya
N
o / T
idak
For A
gent
/ St
aff U
se O
nly
/ Unt
uk E
jen
/ Kak
itang
an S
ahaj
aIn
Com
plia
nce
with
Sec
tion
16(2
) of t
he A
nti-M
oney
Lau
nder
ing,
Ant
i-Ter
roris
m F
inan
cing
and
Pro
ceed
s of
Unl
awfu
l Act
iviti
es A
ct 2
001,
I he
reby
cer
tify
that
th
e Pr
opos
er’s
orig
inal
NRI
C / B
usin
ess
Regi
stra
tion
Cert
ifica
te /
Pass
port
was
ver
ified
and
aut
hent
icat
ed b
y m
e at
the
Poin
t of S
ale.
/ M
enur
ut S
eksy
en 1
6(2)
Ak
ta P
ence
gaha
n Pe
ngub
ahan
Wan
g H
aram
, Pen
cega
han
Pem
biay
aan
Kega
nasa
n da
n H
asil
darip
ada
Aktiv
iti H
aram
200
1, sa
ya d
enga
n in
i men
gesa
hkan
bah
awa
Kad
Peng
enal
an (K
P) /
Sijil
Pen
daft
aran
/ Pa
spor
t asa
l Pen
cada
ng te
lah
disa
hkan
ket
ulen
anny
a ke
tika
urus
nia
ga d
ijala
nkan
.
Nam
e of
Age
nt /
Staff
/ N
ama
Ejen
/ Ka
kita
ngan
Sign
atur
e / T
anda
tang
anD
ate
/ Tar
ikh
NRI
C N
o. /
No.
KP
Ant
i-Mon
ey L
aund
erin
g, A
nti-T
erro
rism
Fin
anci
ng a
nd P
roce
eds o
f Unl
awfu
l Act
iviti
es A
ct 2
001
/ Akt
a Pe
nceg
ahan
Pe
ngub
ahan
Wan
g H
aram
, Pen
cega
han
Pem
biay
aan
Kega
nasa
n da
n H
asil
darip
ada
Aktiv
iti H
aram
200
1
Nam
e of
Pro
pose
r / N
ama
Penc
adan
g
Cove
r Not
e N
o. /
Polic
y N
o. /
No.
Siji
l Ins
uran
s / N
o. P
olis
i
VER
IFIC
ATIO
N /
PEN
GES
AHANAU
TO R
ENEW
AL
INST
RUCT
ION
/ AR
AHAN
PEM
BAH
ARU
AN A
UTO
MAT
IKI h
ereb
y au
thor
ise
AmG
ener
al In
sura
nce
Berh
ad to
deb
it m
y cr
edit
card
bei
ng p
aym
ent o
f pre
miu
m fo
r thi
s pro
posa
l and
all
futu
re p
olic
y re
new
al o
r suc
h ot
her
amou
nt a
s adv
ised
by
AmG
ener
al In
sura
nce
Berh
ad fr
om ti
me
to ti
me
unde
r thi
s Pol
icy.
Saya
mem
beri
kuas
a ke
pada
Am
Gen
eral
Insu
ranc
e Be
rhad
unt
uk m
ende
bitk
an a
kaun
kad
kre
dit s
aya
seba
gai b
ayar
an p
rem
ium
unt
uk c
adan
gan
ini d
an se
mua
pe
mba
haru
an p
olis
i di m
asa
hada
pan
atau
jum
lah
lain
yan
g di
nasi
hatk
an o
leh
AmG
ener
al In
sura
nce
Berh
ad d
ari s
emas
a ke
sem
asa.
Plea
se D
ebit
/ Si
la D
ebit
Cred
it Ca
rd N
o. /
No.
Kad
Kre
dit
Nam
e of
Car
dhol
der /
N
ama
Pem
egan
g Ka
d
Card
Exp
iry D
ate
/ Ta
rikh
Tam
at Te
mpo
h Ka
d
Card
Issu
ing
Bank
/ Ba
nk P
enge
luar
Kad
Not
e / N
ota:
Card
hold
er’s
rela
tions
hip
to In
sure
d m
ust b
e ei
ther
spou
se, p
aren
t or c
hild
. /
Card
hold
er’s
Sign
atur
e (a
s per
car
d)
Hub
unga
n pe
meg
ang
kad
kepa
da P
ihak
Diin
sura
nska
n m
estil
ah p
asan
gan
suam
i ist
eri, i
buba
pa a
tau
anak
. Ta
ndat
anga
n Pe
meg
ang
Kad
(sep
erti
di d
alam
kad
)
(mm
/yyy
y)
(bb/
tttt
)
--
-
-
Mas
ter
Visa
Not
e : P
rem
ium
stat
ed a
re in
clus
ive
of 6
% S
ervi
ce Ta
x. /
Not
a: P
rem
ium
yang
tert
era
adal
ah te
rmas
uk 6
% C
ukai
Per
khid
mat
an.
!