Personal Accident (General) Application Form
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- Leslie Garrett
- 5 years ago
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1 Personal Accident (General) Application Form IMPORTANT NOTE 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. 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. The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. 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. 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 is inaccurate or has changed. GOODS AND SERVICES TAX ( GST ) Important Notice: Please be informed that the Goods and Services Tax ( GST ) will be implemented by the Government of Malaysia with effect from 1 April 2015 at a rate of six (6) per centum. Zurich General Insurance Malaysia Berhad reserves the right to collect from you an amount equivalent to the GST payable on the applicable premium for the policy period, or in the event that the policy period commences before but expires after 1 April 2015, to collect from you an amount equivalent to the GST payable on the applicable premium calculated from 1 April 2015 on a pro-rated basis. Your obligation to pay GST shall form part of the Terms and Conditions in your insurance policy. A. Personal Information i) Applicant s Information Name of Applicant Correspondence Address New NRIC No. Goods and Services Tax (GST) Registration No Goods and Services Tax (GST) Registration Date Company Registration No. Contact No. H/P Country ii) Insured s Information Name of Insured D.O.B Age Sex Race Marital Status Nationality New NRIC No. Occupation Occupational Class Specific Duties 1918/5/P/G/S/M
2 B. Plan Information Product Name Plan Plan Code Period of Insurance From To Proposal Date Benefits Amount Premium Principal Sum Insured Optional Benefits i) ii) iii) iv) Premium : GST 6% : Stamp Duty : Total : C. Questions & Declaration 1) Are you currently insured with any other company? If yes, please state details and the amount insured. Company s Name Personal Accident Life Yes No 2) Do you have any physical defects or health impairments? If yes, please state details. 3) Have you ever made any accident claim during the last 5 years? If yes, please state when and the amount of claim. 4) Are you involved in any of the following activities? If yes, please state details. i) Unlicensed money lending ii) Unlicensed gaming or gambling iii) Any other illegal activities 5) Any other additional information? Additional We may ask you additional questions if required. The questions on this proposal form and any other details we specifically request relate to facts which we consider material to underwriting this insurance. However, because no list of questions can be exhaustive, please consider whether there is any other material information which is known to you which could influence our assessment and acceptance of the risk.
3 DECLARATION AND SIGNATURE 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. I/We agree that this Declaration and the answers above given, as well as any proposal or declaration or statement made in writing by me/ourselves or anyone acting on my/our behalf shall form the basis of the Contract between me/ourselves and the Company, and I/We further agree to accept indemnity subject to the conditions in and endorsed on the Company s Policy and to pay the premium thereunder with sixty (60) days from the Inception date of Policy. I/We hereby give my/our unconditional and unequivocal consent to you and all your related companies to process my/our personal data revealed hereto. You are at liberty to process the data and share the information revealed thereto with any of your service providers and your other related companies provided that the revelation of my/our personal data strictly for the purposes in relation to the insurance which I/we have applied hereto. The consent given hereto is in line with the requirement set forth in the Personal Data Protection Act Date Signature of Proposer FOR OFFICE USE Cover Note No. : Agent Code : Policy No. : NOMINATION FO Policy No. I hereby nominate the following as nominee(s) for the above insurance policy and recall all existing nominees (if any) named earlier (if no trustee has been nominated). Full Name I C No. % of Shares Date of Birth Relationship Address Dated this Day of Signature of Witness : Signature of Applicant : Name : New NRIC No. : Address : Name : New NRIC No. : Address : If your intention is for the nominees(s) named herein to receive the policy benefits beneficially and not as an executor, then you must assign the benefits of the policy to person(s) using the Conditional Assignment Form. Note: 1) The witness must be at least 18 years of age and cannot be a named nominee. 2) A nominee of a Muslim policyowner upon receipt of policy money should distribute the policy moneys in accordance with Islamic Law. 3) Pursuant to Paragraph 5 of Schedule 10 of Financial Services Act 2013, a trust is automatically created if the nominee is a : i) spouse; ii) child or iii) parent who is beng nominated when there is no spouse or child living at the time of making the nomination.
4 Verification of Proposer s Identification To be completed by Insurance Agents, Insurance Brokers or Staff of Insurance Companies relating to the Anti-Money Laundering & Terrorism Financing Act ANTI-MONEY LAUNDERING AND ANTI-TERRORISM FINANCING ACT 2001 (VERIFICATION OF PROPOSER S IDENTIFICATION) Name of Proposer Business Registration No. /NRIC No. In compliance with Section 16(2) of the Anti-Money Laundering And Anti-Terrorism Financing Act 2001, I hereby certify that the Proposer s original New NRIC No./Business Registration Certificate was verified and authenticated by me at the point of sales. Third Party Verification Signature of Insurance Agents, Insurance Brokers or Staff of Insurance Companies Name Date New NRIC No. Note: A copy of the Proposer s New NRIC/Business Registration Certificate must be submitted together with this proposal if the Premium exceeds 50,000 Zurich General Insurance Malaysia Berhad ( V) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax: Call Centre:
5 Borang Permohonan Kemalangan Diri (Am) NOTA PENTING 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. 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. Kewajipan pendedahan diatas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami. 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. 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 at telah berubah. CUKAI BARANGAN DAN PERKHIDMATAN ( GST ) Notis Mustahak Dimaklumkan bahawa Cukai Barangan dan Perkhidmatan ( GST ) akan dikuatkuasakan oleh Kerajaan Malaysia pada 1 April 2015 pada kadar enam (6) peratus. Zurich General Insurance Malaysia Berhad berhak memungut sejumlah amaun bayaran GST yang berpatutan keatas premium yang ditetapkan semasa tempoh polisi, atau sekiranya tempoh polisi bermula sebelum dan berakhir selepas 1 April 2015, memungut daripada pemegang polisi amaun GST keatas premium yang dikira secara pro-rata mulai 1 April Kewajipan pembayaran GST hendaklah tertakluk kepada Terma dan Syarat di dalam polisi insurans. A. Maklumat Peribadi i) Maklumat Pemohon Nama Pemohon No. KP Baru Alamat Surat Menyurat No. Pendaftaran Cukai Barangan dan Perkhidmatan Tarikh Pendaftaran Cukai Barangan dan Perkhidmatan No. Pendaftaran Syarikat No. Tel. Telefon Bimbit Negara ii) Maklumat Yang Diinsuranskan Nama Yang Diinsuranskan Tarikh Lahir Umur Jantina Bangsa Status Perkahwinan Warganegara No. KP Baru Pekerjaan Kelas Pekerjaan Tanggungjawab Khusus 1918/5/P/G/S/M
6 B. Maklumat Pelan Nama Produk Pelan Kod Pelan Tempoh Insurans Dari Hingga Tarikh Cadangan Jumlah Manfaat Premium Jumlah Pokok Diinsuranskan Manfaat Pilihan i) ii) iii) iv) Premium : 6% GST : Setem Duti : Jumlah : C. Soalan-soalan & Perakuan 1) Adakah anda mempunyai polisi insurans dengan syarikat lain? Jika ya, sila beri butir lanjut dan jumlah yang diinsuranskan. Nama Syarikat Kemalangan Diri Hayat Ya Tidak 2) Adakah anda mengalami sebarang kecacatan fizikal atau kelemahan kesihatan? Jika ya, sila beri butir lanjut. 3) Pernahkah anda membuat sebarang tuntutan kemalangan dalam masa 5 tahun kebelakangan ini? Jika ya, sila nyatakan bila dan jumlah tuntutan. 4) Pernahkah anda terlibat dengan mana-mana kegiatan di bawah? Jika ya, sila beri butir lanjut. i) Pinjaman wang tidak berlesen ii) Perjudian tidak berlesen iii) Mana-mana kegiatan haram 5) Sebarang maklumat tambahan yang lain? Tambahan Kami mungkin akan bertanyakan beberapa soalan tambahan jika perlu. Soalan-soalan pada borang cadangan dan lain-lain butiran yang diminta secara khusus berkait dengan fakta-fakta yang dianggap penting oleh pihak kami untuk proses pengunderaitan insurans ini. Walau bagaimanapun, disebabkan tiada senarai soalan-soalan yang lengkap, sila pertimbangkan sama ada terdapat apa-apa maklumat penting yang anda ketahui yang dapat mempengaruhi penilaian dan penerimaan risiko.
7 PENGAKUAN 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. Saya/Kami bersetuju bahawa Pengisytiharan ini dan jawapan yang diberi termasuk sebarang cadangan atau pengisytiharan atau kenyataan yang dibuat secara bertulis oleh saya/kami atau sesiapa yang bertindak bagi pihak saya/kami akan membentuk asas kepada Kontrak di antara saya dan pihak Syarikat, dan saya/kami seterusnya bersetuju menerima indemniti tertakluk kepada syarat-syarat yang telah disahkan dan di endos di dalam Polisi Syarikat. Saya/Kami dengan ini memberikan kebenaran tanpa syarat dan tanpa keraguan kepada pihak syarikat dan semua syarikat-syarikat bersekutunya untuk memproses data peribadi saya/kami yang didedahkan di sini. Pihak syarikat bebas untuk memproses data berkenaan dan berkongsi maklumat yang didedahkan di sini kepada mana-mana penyedia perkhidmatan dan mana-mana syarikat bersekutu yang lain dengan syarat bahawa pendedahan maklumat peribadi berkenaan adalah bertujuan dan berkaitan dengan insurans yang saya/kami pohon di sini. Kebenaran ini diberikan selaras dengan peruntukan di bawah Akta Perlindungan Data Peribadi Tarikh Tandatangan Pencadang UNTUK TUJUAN PEJABAT No. Nota Lindungan : Kod Ejen : No. Polisi : BORANG PENAMAAN No. Polis. Saya dengan ini menamakan yang berikut sebagai penama-penama bagi polisi insurans di atas dan membatalkan semua penama semasa (jika ada) yang dinamakan sebelum ini (jika tiada pemegang amanah yang dilantik). Nama Penuh N o. K/P % Perkongsian Tarikh Lahir Hubungan Alamat Bertarikh Haribulan Tandatangan Saksi : Tandatangan Pemohon : Nama : No. KP Baru : Alamat : Nama : No. KP Baru : Alamat : Jika anda mahukan penama yang dinamakan di sini menikmati faedah polisi sebagai penerima faedah dan bukan sebagai pelaksana polisi, anda mesti menyerah hak faedah polisi kepada penama berkenaan melalui Borang Penyerahan Hak Bersyarat. Nota: 1) Saksi hendaklah berumur sekurang-kurangnya 18 tahun dan tidak boleh dinamakan sebagai penama. 2) Penama bagi pemilik polisi beragama Islam apabila menerima duit polisi, hendaklah mengagihkan duit polisi mengikut Undang- Undang Islam. 3) Mengikut Perenggan 5 daripada Jadual 10 Akta Perkhidmatan Kewangan 2013, suatu amanah terbentuk secara automatik jika penama merupakan : i) suami / isteri; ii) anak, atau iii) ibu bapa yang dinamakan apabila tiada suami / isteri atau anak yang hidup ketika penamaan dibuat.
8 Pengesahan Identiti Pencadang Insurans Untuk dilengkapkan oleh Ejen Insurans, Broker Insurans atau Kakitangan Syarikat Insurans berkaitan dengan Akta Pencegahan Pengubahan Wang Haram dan Pencegahan Pembiayaan Keganasan AKTA PENCEGAHAN PENGUBAHAN WANG HARAM DAN PENCEGAHAN PEMBIAYAAN KEGANASAN 2001 (PENGESAHAN IDENTITI PENCADANG INSURANS) Nama Pencadang Insurans No. Kad Pengenalan Baru/No. Pendaftaran Perniagaan Selaras dengan pematuhan Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram dan Pencegahan Pembiayaan Keganasan 2001, Saya, dengan ini mengesahkan bahawa Nombor Kad Pengenalan Baru/Sijil Pendaftaran Perniagaan asal pencadang telah disahkan ketulenannya ketika urusniaga dijalankan. Pengesahan Pihak Ketiga Tandatangan Ejen Insurans, Broker Insurans atau Kakitangan Syarikat Insurans Nama Tarikh No. Kad Pengenalan Baru Nota: Salinan Kad Pengenalan Baru/Sijil Pendaftaran Perniagaan Pencadang hendaklah disertakan bersama-sama dengan borang cadangan ini sekiranya bayaran Premium melebihi 50,000 Zurich General Insurance Malaysia Berhad ( V) Tingkat 11, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Faks: Pusat Panggilan:
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