My Auto Personal Accident Cover
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- Philomena Tyler
- 6 years ago
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1 My Auto Personal Accident Cover
2 My Auto Personal Accident Cover Coverage a. Any person who is travelling in the Insured Vehicle. Age limits in respect of each insured person: 5 to 70 Extended Coverage b. The Insured, his / her spouse and any of their children between 5 to 18 years of age whilst i) as a pedestrian in an accident involving any vehicle including motorcycles / scooters and pedal cycles. ii) driving or travelling as a passenger in any vehicle other than motorcycles / scooters iii) travelling as a fare paying passenger on any railway train, ferry boat or passenger ship / aircraft Geographical Limits Within Malaysia, Singapore and Brunei Benefits in respect of each insured person Bodily Injury caused by violent accidental external and visible means which injury shall solely and independently of any other cause results within twelve (12) months of the happening of an accident. Benefit per unit Benefit A Death RM20,000 Benefit B Total and irrecoverable loss of all sight in both eyes Total loss by physical severance of both hands or both feet or one hand and one foot Total loss by physical severance of one hand or one foot together with the total and Total and irrecoverable loss of all sight in one eye Total loss by physical severance of one hand or one foot or necessitate Benefit C Medical and Surgical Treatment for such injury in respect of any one accident Limit RM2,500 1
3 Unit Premium (excluding stamp duty) Seating Capacity 5 Each Additional Passenger Please tick ( ) 1 RM75 RM15 2 RM125 RM25 3 RM175 RM35 4 RM225 RM45 5 RM275 RM55 The premium is subject to an additional 6% GST in accordance with GST Act 2014 with effect from 1 April 2015 and Stamp Duty RM10. 2
4 THIS PAGE IS LEFT BLANK INTENTIONALLY
5 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 this 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. 4
6 Proposal form Name of Proposer NRIC No. Age Postal Address City Postal Code Tel (H) (O) (H/P) Period of Insurance From D D M M Y Y Y Y to D D M M Y Y Y Y Bus. Reg. No. Occupation Goods and Services Tax (GST) Registration No. Goods and Services Tax (GST) Registration Date Particulars Of Insured Vehicle Vehicle Registration No. Make / Model Type of Body Seating Capacity Premium Gross Premium RM GST (6%) RM Stamp Duty RM Total If at the time of accident the number of passengers including driver shall exceed the seating capacity declared the Company shall pay the proportion of the loss accordingly. If the Insured Vehicle is Company Owned, please state name of the nominated driver / user other than the paid driver otherwise Cover will be restricted to persons travelling in the Insured Vehicle only. Named Driver 5
7 DECLARATION 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 agree that this Declaration and the answers given above, as well as any proposal or declaration or statement made in writing by me or any one acting on my behalf shall form the basis of the Contract between me and the Company, and I further agree to accept indemnity subject to the conditions in and endorsed on the Company s Policy and to pay the premium there under within sixty (60) days from the inception date of the 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 Signature of Proposer Date D D M M Y Y Y Y Credit Card: Master Visa Card Number FOR OFFICE USE Cover Note No. Agent Code Policy No. 6
8 Nomination form Proposal / Policy Number 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). Name IC/BC No. Date of Birth Address Relationship % of shares Dated this day of Signature of Witness Signature of Proposer Name IC No. Address Name IC No. Address 7
9 If your intention is for the nominee(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 policy owner upon receipt of policy money should distribute the policy moneys in accordance with Islamic Law. *3. Pursuant to Paragraph 5 Schedule 10 Financial Services Act 2013, a trust is automatically created if the nominee is a :- i) spouse, ii) child or iii) parent who is being nominated when there is no spouse or child living at the time of making the nomination. 8
10 Verification of Proposer s Identification To be completed by Insurance Agents, Insurance Brokers or Staff of Insurance Companies relating to the Anti-Money Laundering & Anti-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 New NRIC No. Date D D M M Y Y Y Y Note: A copy of the Proposer s New NRIC/Business Registration Certificate must be submitted together with this proposal if the Premium exceeds RM50,000. 9
11 Perlindungan Kemalangan Peribadi My Auto Perlindungan a. Sesiapa yang menaiki Kenderaan Diinsuranskan. Had usia bagi setiap orang diinsuranskan: 5 hingga 70 tahun Perlindungan Lanjutan b. Orang Diinsuranskan, suami / isteri dan mana-mana anak mereka yang berusia antara 5 hingga 18 tahun semasa i) sedang berjalan kaki apabila mengalami kemalangan melibatkan sebarang kenderaan termasuk motosikal / skuter dan kenderaan kayuh. ii) memandu atau menaiki sebagai penumpang mana-mana kenderaan selain daripada motosikal / skuter iii) menaiki sebagai penumpang yang membayar tambang dalam mana-mana kereta api di atas landasan, bot feri atau kapal / pesawat penumpang. Had Geografi Di dalam Malaysia, Singapura dan Brunei Manfaat bagi setiap orang diinsuranskan Kecederaan Badan Kecederaan Badan yang disebabkan oleh kejadian luaran, tidak disengajakan, malang, dan ketara di mana kecederaan semata-mata dan secara khusus bukan berpunca daripada sebab lain, dalam tempoh dua belas (12) bulan selepas berlaku kemalangan. Manfaat seunit Manfaat A Kematian RM20,000 Manfaat B Kehilangan penglihatan penuh dan tidak boleh pulih pada kedua-dua belah mata Kehilangan penuh akibat kedua-dua belah tangan dan kaki atau sebelah tangan dan sebelah kaki terputus secara fizikal Kehilangan penuh akibat sebelah tangan atau sebelah kaki terputus secara fizikal bersama Kehilangan penglihatan penuh dan tidak boleh pulih pada sebelah mata Kehilangan penuh akibat sebelah tangan atau sebelah kaki terputus secara fizikal Manfaat C Rawatan Perubatan dan Pembedahan bagi kecederaan tersebut bagi mana-mana satu kemalangan Had RM2,500 10
12 Unit Premium (tidak termasuk duti setem) Kapasiti Tempat Duduk 5 Setiap Penumpang Tambahan Sila tandakan ( ) 1 RM75 RM15 2 RM125 RM25 3 RM175 RM35 4 RM225 RM45 5 RM275 RM55 Premium adalah tertakluk kepada tambahan 6% GST menurut Akta Cukai Barangan dan Perkhidmatan 2014 mulai 1 April 2015 dan Duti Setem RM10. 11
13 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 atau 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 ke atas premium yang ditetapkan semasa tempoh polisi, atau sekiranya tempoh polisi bermula sebelum dan berakhir selepas 1 April 2015, memungut daripada pemegang polisi amaun GST premium yang dikira secara pro-rata mulai 1 April Kewajipan pembayaran GST hendaklah tertakluk kepada Terma dan Syarat di dalam polisi insurans. 12
14 Borang cadangan Nama Pencadang No. KP Umur Alamat Pos Bandar Poskod Tel (R) (P) (T/B) Tempoh Insurans Dari H H B B T T T T hingga H H B B T T T T No. Pendaftaran Perniagaan Pekerjaan No. Pendaftaran Cukai Barangan dan Perkhidmatan (GST) Tarikh Pendaftaran Cukai Barangan dan Perkhidmatan (GST) Butir-Butir Kenderaan Diinsuranskan No. Pendaftaran Kenderaan Jenis / Model Jenis Badan Kapasiti Tempat Duduk Premium Premium Kasar RM GST (6%) RM Duti Setem RM Jumlah Jika semasa kemalangan berlaku, bilangan penumpang termasuk pemandu melebihi kapasiti tempat duduk yang diisytiharkan, Syarikat akan membayar kerugian mengikut perkadaran yang sewajarnya. Jika Kenderaan Diinsuranskan Dimiliki oleh Syarikat, sila nyatakan nama pemandu / pengguna yang dinamakan selain daripada pemandu berbayar, jika tidak perlindungan hanya terhad kepada orang yang menaiki Kenderaan Diinsuranskan sahaja. Pemandu yang Dinamakan 13
15 PERAKUAN 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 juga bersetuju bahawa Perakuan dan jawapan yang diberikan di atas, serta sebarang cadangan atau perakuan atau kenyataan yang dibuat secara bertulis oleh saya atau sesiapa yang bertindak bagi pihak saya akan menjadi asas Kontrak di antara saya dengan pihak Syarikat, dan saya seterusnya bersetuju untuk menerima indemniti yang tertakluk kepada syarat di dalam dan diendors pada Polisi Syarikat dan membayar premium baginya dalam tempoh (60) hari dari tarikh permulaan polisi. Saya/Kami dengan ini memberikan persetujuan nyata dan tidak bersyarat kepada Syarikat dan semua syarikat berkaitannya untuk memproses data peribadi saya/kami yang didedahkan di dalam ini. Syarikat berhak untuk memproses data dan berkongsi maklumat yang didedahkan di dalamnya dengan mana-mana pembekal perkhidmatan syarikat dan juga syarikat berkaitan yang lain dengan syarat pendedahan data peribadi saya/kami adalah semata-mata untuk tujuan insurans yang telah saya/kami mohon di dalam ini. Persetujuan yang diberikan di dalam ini adalah sejajar dengan keperluan yang ditetapkan dalam Akta Perlindungan Data Peribadi Tandatangan Pencadang Tarikh H H B B T T T T Kad Kredit: Master Visa Nombor Kad UNTUK KEGUNAAN PEJABAT SAHAJA No. Nota Lindungan Kod Ejen No. Polisi 14
16 Borang penamaan Nombor Cadangan / Polisi Saya dengan ini menamakan yang berikut sebagai penama bagi polisi insurans di atas dan menarik balik semua penama sedia ada (jika ada) yang telah dinamakan sebelum ini (jika tiada pemegang amanah dinamakan). Nama No. KP/SB Tarikh Lahir Alamat Hubungan % bahagian Bertarikh hari bulan Tandatangan Saksi Tandatangan Pencadang Nama No. KP Alamat Nama No. KP Alamat 15
17 Jika anda bercadang untuk membolehkan penama* yang dinamakan di dalam ini menerima manfaat sebagai benefisiari dan bukan sebagai wasi, maka anda mesti menyerahkan hak manfaat polisi kepada orang tersebut menggunakan Borang Penyerahan Hak Bersyarat. Perhatian: 1. Saksi mesti berusia 18 tahun dan tidak boleh menjadi penama yang dinamakan. 2. Penama pemilik polisi beragama Islam, apabila menerima wang polisi, hendaklah mengagihkan wang polisi menurut Undang-Undang Islam. *3. Menurut Perenggan 5 Jadual 10 Akta Perkhidmatan Kewangan 2013, amanah diwujudkan secara automatik jika penama ialah :- i) suami / isteri, ii) anak atau iii) ibu bapa yang dinamakan apabila tiada suami / isteri atau anak yang hidup semasa penamaan dibuat. 16
18 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 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 No. Kad Pengenalan Baru Tarikh H H B B T T T T Nota: Salinan Kad Pengenalan Baru/Sijil Pendaftaran Perniagaan Pencadang hendaklah disertakan bersama-sama dengan borang cadangan ini sekiranya bayaran Premium melebihi RM50,000 17
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20 Zurich General Insurance Malaysia Berhad ( V) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax: Call Centre: The trademarks depicted are registered in the name of Zurich Insurance Company Ltd in many jurisdictions worldwide 1007/5/P/G/S/M
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