INsurance

UM-NM-FA13(E)
REV: A
KURNIA TRAVEL SUPREME INSURANCE POLICY SCHEDULE

JADUAL POLISI INSURANS KURNIA TRAVEL SUPREME
Schedule attaching to and forming part of the e-Policy. / Jadual yang disertakan adalah sebahagian daripada e-Polisi.
Name and Address of Insured / Nama dan Alamat Pihak Diinsuranskan
SARAVANAN A/L MUTTIA
NO.15, JALAN JELAWAT 9.
TAMAN SRI PUTRA, PKNS,
BANTING
e-Policy No.
No. e-Polisi
BGA0008790
Agent Code & Name

Kod & Nama Ejen
G59800-00 AMGENERAL
INSURANCE BERHAD
Gross Premium
Premium Kasar
RM 425.00
Business Reg. No./ New/Old NRIC No.

25.00% Rebate
No Pendaftaran Syarikat/ No KP Baru/ Lama 25.00% Rebat
RM 106.25
Postcode / Poskod :
42700 BANTING
Business or Occupation
Perniagaan atau Pekerjaan :
CLERK - OFFICE-
750728145345
0% Service Tax
0% Cukai Perkhidmatan
Period of Insurance / Tempoh Insurans

Stamp Duty
Leaving Malaysia on 00:00:01 AM 18-03-2015 and returning on 27-03-2015
Bertolak dari Malaysia pada 00:00:01 AM 18-03-2015 dan kembali pada 27-03-2015 Duti Setem
Total Payable
(Note : maximum period any one trip shall not exceed six (6) months)
(Nota : Tempoh maxima setiap perjalanan adalah tidak melebihi enam (6) bulan)
RM 0.00
RM 10.00
RM 328.75
Jumlah Berbayar
Area cover
: Shall be limited to the following countries only:Malaysia (East to West Malaysia and vice versa), Australia, Brunei, Cambodia, China (excluding
Mongolia & Tibet), Hong Kong,India, Indonesia, Japan, Korea, Laos, Myanmar, New Zealand,
Pakistan, Philippines, Singapore, Sri Lanka, Taiwan, Thailand and Vietnam
First Country of Arrival Abroad
: India
Final Destination
: Malaysia
Flight.No
: AK37
Plan Purchased /
Pelan Dibeli
As per list attached

Seperti yang dilampirkan
Descriptions of benefits / Faedah Deskripsi

As per list attached / Seperti yang dilampirkan
Nominee : As per list attached / Seperti yang dilampirkan
Page 1
ISSUING OFFICE : E-MARKETING, AMGENERAL INSURANCE BERHAD, MENARA KURNIA, NO 9 JALAN PJS 8/9, 46150 PETALING JAYA
Tel : 03-78753333 Fax : 03-78759933
BGA0008790

Attaching to and forming part of e-Policy No. : / Yang disertakan adalah sebahagian daripada No. e-Polisi : BGA0008790
Replacing Cover Note No.
Gantian No. Nota
Perlindungan
Previous Policy No.

No. Polisi Terdahulu
Date of Proposal or
Declaration
Tarikh Cadangan atau
Pengisytiharan
25-02-2015
Date of Issue / Time

Tarikh Dikeluarkan / Waktu
Issued By / Dikeluarkan Oleh

AMGENERAL INSURANCE BERHAD
AMGENERAL INSURANCE BERHAD
NO. 9 JALAN PJS 8/9
46150 PETALING JAYA
SELANGOR
Tel : 03-78753333
Fax : 03-78759933
For / Untuk
AmGeneral Insurance Berhad
Authorised Signature /
Tandatangan Yang Diberi Kuasa
25-02-2015 / 07:02:13PM
07BG750213-1
IMPORTANT NOTICE / NOTIS PENTING

1. The Insured shall read this Policy carefully, and if any error or misdescription be found herein, or if the cover is not in accordance with the wishes of the Insured, advice should at once be given to
the Company and the Policy returned for alteration.
Pihak Diinsuranskan hendaklah membaca Polisi ini dengan teliti, dan jika terdapat kesilapan atau keterangan yang salah, atau jika nota perlindungan tidak memenuhi kehendak Pihak
Diinsuranskan, Pihak Diinsuranskan hendaklah memberitahu kepada Syarikat dan mengembalikan Polisi untuk membuat pembetulan sewajarnya.
2. Duty of Disclosure - 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 the rates
and terms to be applied.
KEWAJIPAN PENDEDAHAN - 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 samada
untuk menerima atau tidak risiko dan kadar dan terma yang hendak dipakai.
3. Any changes in the information given must be reported to the Company immediately otherwise the Company may resume the right to decline all liability.
Sebarang pertukaran informasi diberi mesti dilaporkan kepada Syarikat serta merta, jika tidak Syarikat berhak menolak sebarang liabiliti.
4. In the event of any occurrence which might give rise to a claim, notice should be given immediately to the nearest Branch Office or your Servicing Agent followed by such further steps, as are
required by the Conditions of the Policy.
Jika berlaku apa-apa kejadian di mana suatu tuntutan boleh dibuat, notis hendaklah diberikan dengan serta merta kepada pejabat cawangan yang berdekatan atau agen perkhidmatan diikuti
dengan langkah-langkah yang diperlukan seperti tercatat di dalam Syarat-Syarat Polisi.
5. Insured who is not satisfied with the course of the action or decision of the Company, may seek redress or assistance with the Financial Mediation Bureau or alternatively to approach Bank Negara
Malaysia's Laman Informasi dan Nasihat (LINK), addressed below:
Pihak Yang Diinsuranskan yang tidak berpuas hati dengan segala tindakan atau keputusan Syarikat boleh memperolehi rujukan atau bantuan dengan Biro Pengantaraan Kewangan atau
seterusnya menghadap kepada Bahagian Perkhidmatan Pelanggan Bank Negara Malaysia, seperti alamat tertakluk di bawah:
a.
Financial Mediation Bureau ( FMB )

Level 25, Blok Utama,
Dataran Kewangan Darul Takaful
No. 4, Jalan Sultan Sulaiman
50000 Kuala Lumpur
Tel : 03 2272 2811
Fax : 03 2274 5752
b.
Jabatan Konsumer Dan Amalan Pasaran

8B, Bangunan Bank Negara Malaysia
Jalan Dato Onn
50480 Kuala Lumpur
Tel : 03 2698 8044
Fax : 03 2693 4051
Page 2
BGA0008790

Attaching to and forming part of e-Policy No. : / Yang disertakan adalah sebahagian daripada No. e-Polisi : BGA0008790
Item No. Insured Person / NRIC /Passport No.
No. Item Birth Certificate No.
Orang yang diinsuranskan / No KP
Baru / Pasport / Sijil Kelahiran
Age
Umur
Plan Purchase
Pelan Dibeli
Sum Insured
Jumlah Insurankan
(RM)
Nominee / Relationship / Percentage

Penama / Hubungan / Peratus
THIYAGU RAJAGOPAL
PASSPORT NO : A34597010
33
PLAN A
100,000.00
ESTATE
100
SUSHEELA MUNUSAMY
39
PLAN A
100,000.00
ESTATE
100
DARVIN MANIMARAN
14
PLAN A
100,000.00
ESTATE
100
KUNASUNTHARI ARUMUGGAM
49
PLAN A
100,000.00
ESTATE
100
RAJAMMAL ARUMUGGAM
52
PLAN A
100,000.00
ESTATE
100
PARVATHY ARUMUGGAM
54
PLAN A
100,000.00
ESTATE
100
AMUTHA KANDASAMY
34
PLAN A
100,000.00
ESTATE
100
MALLIGA ALUMALAI
53
PLAN A
100,000.00
ESTATE
100
VIJAYALETCHUMI RAJOO
50
PLAN A
100,000.00
ESTATE
100
10
NITHIANANTHA RAO SEKARAN

26
PLAN A
100,000.00
ESTATE
100
11
SALINI RAMALINGAM
26
PLAN A
100,000.00
ESTATE
100
12
VALAMAH RATNAM
51
PLAN A
100,000.00
ESTATE
100
13
RAMALINGAM SOMASUNDRAM
55
PLAN A
100,000.00
ESTATE
100
14
SHUBASHINI TAMIL MANIMOLI

35
PLAN A
100,000.00
ESTATE
100
15
VELLAMAL PONNUSAMY
48
PLAN A
100,000.00
ESTATE
100
16
JAYALETCHUMI JAYARAMAN
44
PLAN A
100,000.00
ESTATE
100
Page 3
BGA0008790
17
SARAVANAN MUTTIA
40
PLAN A
Page 4
100,000.00
ESTATE
100
BGA0008790
INSURED NAME
: SARAVANAN A/L MUTTIA
COVER NOTE NO.
: BGA0008790
PRIVACY CLAUSE
1.0
PRIVACY CLAUSE
1.1
You confirm that you have read, understood and agree to be bound by the Privacy Notice of AmGeneral Insurance
(which is available at www.amassurance.com.my and www.kurnia.com) and the clauses herein, as may relate to
the processing of your personal information. For the avoidance of doubt, you agree that the said Privacy Notice
shall be deemed to be incorporated by reference into this Insurance Policy.
1.2
In the event you provide personal and/or financial information relating to third parties, including information relating
to your next-of-kin and dependents, for the purpose of operating the Insurance Policy with AmGeneral or otherwise
subscribing to AmGenerals products and services, you:
a.
b.
c.
confirm that you have obtained their consent or are otherwise entitled to provide the information to
AmGeneral and for AmGeneral to use it in accordance with this Insurance Policy;
agree to ensure that the personal and financial information of the said third parties is accurate and
update AmGeneral in writing in the event of any change to the said personal and financial information;
and
agree to AmGenerals right to terminate the Insurance Policy should such consent be withdrawn by any
of the said third parties
1.3
Even after you have provided AmGeneral with any information, you have the option to withdraw the consent given
earlier. In such instances, AmGeneral will have the right to not provide or discontinue the provision of the
Insurance Policy that is/are linked with such information.
1.4
You agree that the Company and its related companies may contact you about products and services and offers,
which the Company and its related companies believe may be of interest to you, through various channels of
communication.
1.5
In the event you do not wish to consent to use your personal data to receive marketing of products and services
by the Company and its related companies, you may contact AmGeneral as per below details or you may contact
AmGenerals nearest Branch Manager:
Kurnia Insurans - Customer Service Executive
Customer Care Centre : 1-800-88-6333
Complaint Contact No. : 03-7876 1158
E-mail : customercomplaint@kurnia.com
Or
Customer Advocate Unit,
Compliance & Operational Assurance Department
AmGeneral Insurance Berhad,
Level 23, Menara Kurnia ,
No 9 Jalan PJS 8/9 46150 Petaling Jaya, Selangor
1.6
AmGeneral reserves the right to amend this Section from time to time at AmGenerals sole discretion by providing
notice to you.
---------- Please bring this document during your travel -----------
Kurnia Travel Supreme

Policy / Cover Note No.
Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
Name of Insured Person
THIYAGU RAJAGOPAL
NRIC / B.C. / Passport
A34597010
For Emergency Medical Evacuation and Repatriation

Please contact: Asia Assistance Network (M) Sdn. Bhd.
+603-78415750 & +603-76283770

This document is issued by Kurnia Insurans, a division of AmGeneral Insurance Berhad
and it is strictly non-transferable. Use of this document is subject to terms and conditions
as stipulated in the insurance policy.
For more information, visit www.kurnia.com
If found, please return to:
Menara Kurnia, No.9, Jalan PJS 8/9
46150 Petaling Jaya,
P.O.Box 8607, 46792 Petaling Jaya.
Selangor Darul Ehsan, Malaysia.

Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
SUSHEELA MUNUSAMY
A34586416

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
DARVIN MANIMARAN
A34586417

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
KUNASUNTHARI ARUMUGGAM
A34457176

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
RAJAMMAL ARUMUGGAM
A27518753

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
PARVATHY ARUMUGGAM
A34584844

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
AMUTHA KANDASAMY
A34586411

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
MALLIGA ALUMALAI
A33582769

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
VIJAYALETCHUMI RAJOO
A33898295

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
NITHIANANTHA RAO SEKARAN
A32482765

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
SALINI RAMALINGAM
A32412010

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
VALAMAH RATNAM
A34440234

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
RAMALINGAM SOMASUNDRAM
A34440237

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
SHUBASHINI TAMIL MANIMOLI
A34586328

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
VELLAMAL PONNUSAMY
A26746076

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
JAYALETCHUMI JAYARAMAN
A33758443

+603-78415750 & +603-76283770


Period of Cover :
BGA0008790
18-03-2015 To 27-03-2015
SARAVANAN MUTTIA
A34597421

+603-78415750 & +603-76283770

KURNIA TRAVEL SUPREME

LIMIT PER PERSON /
EVENT
TYPES OF BENEFITS
BENEFIT 1 - PERSONAL ACCIDENT
A. Accidental Death
SUM INSURED
PLAN A
PLAN B
INDIVIDUAL
B. Permanent Total Disablement
Per Adult
Per Child
Per Adult / Child
100,000
25,000
100,000
300,000
75,000
300,000
C. Loss of One or More Limbs or One or Both Eyes
Per Adult / Child
100,000
300,000
Age up to 70 years
100,000
300,000
Age above 70 years
50,000
150,000
2B. Compassionate Visitation (Due to Hospitalisation of Insured Person While Abroad

including East to West Malaysia and Vice Versa)
Reimburses accommodation and travelling expenses of a relative/friend required on medical
advice to travel or remain behind with the Insured Person
5,000
7,500
2C. Compassionate Visitation (Due to Death of Insured Person While Abroad including
East to West Malaysia and Vice Versa)
Reimburses accommodation and travelling expenses of a relative/friend assisting burial or
cremation of the Insured Person
5,000
7,500
15,000
30,000
500
1,000
500
500
5,000
5,000
10,500
10,500
Per Adult / Child
2,500
5,000
Per Adult / Child
2,500
5,000
Per Adult / Child
500
1,000
Per Adult / Child
1,500
3,000
Per Adult / Child
1,000,000
1,000,000
Per Adult / Child
10,000
20,000
Per Adult / Child
2,500
5,000
500,000
1,000,000
5,000
10,000
BENEFIT 2 - MEDICAL AND OTHER EXPENSES

2A. Medical Expenses
Covers medical and hospital expenses including cost of emergency dental surgical incurred
overseas as a result of accidental injuries/or illness
2D. Follow Up Medical Treatment

Reimburses follow up treatment within ninety (90) days after returning to Malaysia
Per Adult / Child
2E. Alternative Medicine

Reimburses medical treatment expenses by traditional medical practitioner, osteopath,
physiotherapist and/or chiropractor
2F. Child Care Benefit
Reimburses accommodation and travelling expenses of an Immediate Family
Member/relative/friend of Insured Person to take care his/her child(ren) while Insured Person
is hospitalised abroad
Per day
Per Event
BENEFIT 3 - HOSPITAL ALLOWANCE (RM350 PER DAY / MAX. 30 DAYS)

Pays RM350 per day for every complete day hospitalisation while abroad
BENEFIT 4 - BAGGAGE AND PERSONAL EFFECTS
Reimburses loss or damage to your baggage and personal effects. Maximum RM500 any one
article/pair/set article
BENEFIT 5 - LOSS OF MONEY AND/OR TRAVEL DOCUMENTS
Pays for loss of money and/or cost of obtaining replacement travel documents due to theft
BENEFIT 6 - DELAYED BAGGAGE
Pays RM250 for every complete and consecutive six (6) hours, if checked in bagagge delay
upon arrival at abroad destination
BENEFIT 7 - TRAVEL DELAY
Pays RM250 for every complete and consecutive six (6) hours delayed, based on the
scheduled departure time of conveyance
BENEFIT 8 - PERSONAL LIABILITY
Covers Insured Person's legal liability to third parties for bodily injury and/or loss of or damage
to property
BENEFIT 9 - LOSS OF DEPOSIT OR CANCELLATION / CURTAILMENT
9A. Loss of Deposit or Cancellation
Reimburses for irrecoverable travel expenses paid in advance if trip is cancelled due to
covered events
9B. Curtailment
Reimburses unused and non-refundable portion of pre-paid travelling costs, if trip is curtailed
due to covered events
BENEFIT 10 - HIJACKING
Pays RM1,250 for every complete and consecutive twenty four (24) hours of hijack
BENEFIT 11 - EMERGENCY MEDICAL EVACUATION AND REPATRIATION
Provides emergency transportation and medical assistance en route to the nearest hospital in
the event the Insured Person suffers critical medical conditions due to accident or illness while
abroad. In the event the Insured Person is to be repatriated back to Malaysia for continuing
treatment, provided it is deemed medical necessary
BENEFIT 12 - REPATRIATION OF MORTAL REMAINS
Pays expenses incurred for burial or cremation for death abroad or expenses for transporting
the mortal remain or ashes back to Malaysia
Page 1 of 2
Per Adult / Child
KURNIA TRAVEL SUPREME

LIMIT PER PERSON /
EVENT
TYPES OF BENEFITS
BENEFIT 14 - MISSED DEPARTURE
Pays additional accommodation and travel costs incurred while returning to Malaysia, due to
mechanical breakdown of common carrier
BENEFIT 15 - REROUTING OF TRAVEL
Pays if the common carrier is delayed for complete six (6) consecutive hours as a result of
strike or industrial action, adverse weather conditions or mechanical breakdown.
SUM INSURED
PLAN A
PLAN B
INDIVIDUAL
Per Adult / Child
500
1,000
Per Adult / Child
100
200
7,500
10,000
BENEFIT 16 - CHILD EDUCATION FUND

Pays when the Insured Person dies abroad due to accident and has surviving child(ren)
BENEFIT 17 - CREDIT CARD INDEMNITY UPON ACCIDENTAL DEATH

Reimburses outstanding credit card expenses incurred abroad upon accidental death
Per Adult / Child
500
1,000
BENEFIT 18 - HOME CONTENTS

Pays for loss or damage to your home contents as a result of fire or theft
Per Adult / Child
500
1,000
Per Adult / Child
150
250
Per Adult / Child
500
1,000
500
1,000
50
100
BENEFIT 19 - LOSS OF USE OF HOTEL FACILITIES (PER DAY / MAX. 15 DAYS)

Reimburses additional expenses for alternative accommodation as a result of fire, flood, riot,
strike or industrial action of the booked hotel
BENEFIT 20 - RENTAL VEHICLE EXCESS COVER
Reimburses any excess/deductible which Insured Person is liable under car rental contract in
the event of accident while abroad
BENEFIT 21 - ADDITIONAL COSTS OF RENTAL CAR RETURN

Reimburses additional cost of rental vehicle if Insured Person is unable to return the vehicle on
Per Adult / Child
time due to injury or illness which requires hospitalisation while abroad
BENEFIT 22 - EMERGENCY MOBILE PHONE CHARGES
Reimburses on International mobile phone charges while Insured Person is hospitalised
abroad.
Page 2 of 2
Per Adult / Child
UW-NM-F134
REV:
NOMINATION FORM / BORANG PENAMAAN

(In accordance with Section 163 and/or Section 166 of the Insurance Act 1996)
(Mengikut Seksyen 163 dan/atau Seksyen 166 Akta Insurans 1996)
Cover Note/Policy Number(s)
No. Nota Perlindungan/Polisi :
NOTE:
1. A policy owner who has attained the age of 18 years may
nominate a natural person to receive policy moneys upon his
death.
NOTA:
1. Pemegang polisi yang telah menjangkau usia 18 tahun boleh
melantik
penama untuk menerima wang polisi selepas
kematiannya.
2. If your intention is for your nominee (other than your spouse,

child or, where there is no spouse or child, your parent), to
receive the policy benefits beneficially and not as an executor,
you are required to assign the policy benefits to your nominee.
2. Jika anda bercadang penama anda (selain daripada suami/isteri,

anak atau jika tiada suami/isteri atau anak, ibu bapa anda)
menerima manfaat polisi sebagai waris dan bukan wasi, anda
mesti menyerahkan hak polisi kepadanya.
3. For Non-Muslims: If you nominate either your spouse or child or,

where there is no spouse or child, your parent, to receive the
policy moneys, there shall be a statutory trust in favour of the
nominee as beneficiary pursuant to the Insurance Act 1996; and
you should appoint a trustee over the policy moneys.
3. Untuk Orang Bukan-Islam: Jika penama anda sama ada

suami/isteri atau anak, jika tiada suami/isteri atau anak, ibu
bapa anda, untuk menerima wang polisi, akan membentuk suatu
amanah yang memihak kepada penama-penama mengikut Akta
Insurans 1996; anda mesti melantik pemegang amanah untuk
menerima wang polisi.
4. For Muslims: Your nominee shall upon receipt of the policy

moneys distribute it in accordance with Islamic Law. The section
for the appointment of trustee is not applicable to you.
5. The nomination must be witnessed by a person of sound mind
who has attained the age 18 years and who is not a nominee
herein.
4. Untuk Orang Islam: Penama yang dilantik oleh anda setelah

menerima wang polisi hendaklah mengagihkan wang tersebut
menurut undang-undang Islam. Bahagian perlantikan pemegang
amanah adalah tidak berkenaan.
5. Penamaan mesti disaksikan oleh seorang saksi yang waras dan
telah mencapai usia 18 tahun dan beliau bukan seorang penama.
NOMINATION / PENAMAAN
I, the Policy Owner, hereby nominate the following nominee(s) to receive the policy moneys for the above Policy upon my death.
Saya, Pemegang Polisi, melantik penama-penama berikut untuk menerima wang polisi untuk Polisi tersebut di atas ini selepas kematian
saya.
Name
Nama
NRIC/BC No.
No. K.P. Baru /
Sijil Kelahiran
Date of Birth
Tarikh Lahir
Relationship
Hubungan
Share
Bahagian
(%)
Address
Alamat
APPOINTMENT OF TRUSTEE / PERLANTIKAN PEMEGANG AMANAH

This part is only applicable to Non-Muslims who have nominated either their spouse or child or, where there is no spouse or child, their parents to
receive the policy moneys.
Bahagian ini perlu di isi oleh mereka yang bukan beragama Islam yang menamakan sama ada suami/isteri atau anak-anak, ibu bapa (jika tiada suami
/isteri atau anak-anak semasa penamaan) sebagai penerima wang polisi.
I, the Policy owner, hereby appoint the following person(s) to be the trustee(s) of the policy moneys payable under the above mentioned policy
upon my death.
Saya, Pemegang Polisi, melantik orang-orang berikut sebagai pemegang amanah untuk wang polisi ini selepas kematian saya.
Name
Nama
NRIC No.
No. K.P Baru
Date of Birth
Tarikh Lahir
Relationship
Hubungan
Address
Alamat
Dated this....................................... Day of ................................... Month ................................... Year

Bertarikh
Hari
Bulan
Tahun
Tandatangan Saksi
Tandatangan Pemegang Polisi

Nama
No. Kad Pengenalan
Alamat
1.
2.
3.
4.
5.
Nama
No. Kad Pengenalan
Alamat
1. Penamaan akan berkuatkuasa oleh pemegang polisi ke atas diri

sendiri bagi persediaan untuk pembayaran wang polisi atas
kematiannya.
2. Apabila membuat penamaan, pemegang
polisi hendaklah
memberitahu penanggung insurans nama penama, no. kad
pengenalan atau no. sijil kelahiran, tarikh lahir, hubungan,
alamat serta pengagihan bahagian.
3. Sekiranya terdapat lebih dari seorang penama, pemegang polisi
akan mengarah supaya pembahagian tertentu perlu dibayar
kepada penama yang dicalonkan, jika tiada arahan dari
pemegang polisi, penanggung insurans akan membuat bayaran
sama rata kepada penama-penama tersebut.
4. Penamaan oleh pemegang polisi boleh dibatalkan seperti
berikut:
i) kematian penama
ii) notis bertulis daripada pemegang polisi
iii) penamaan yang seterusnya
Seorang pemegang polisi tidak boleh membatalkan penamaan
melalui wasiat, amanah atau sebarang perlakuan lain, kaedah
atau apa cara sekalipun.
6.
5. Sekiranya penama meninggal dunia selepas kematian pemegang

polisi tetapi sebelum menerima sebarang wang polisi, wang
tersebut akan dibayar kepada hartanah penama.
7.
6. Sekiranya terdapat lebih daripada satu penama dan salah satu

penama meninggal terdahulu daripada pemegang polisi, untuk
penyelesaian pembahagian penama yang mati jika tiada
sebarang pencalonan lain oleh pemegang polisi, maka
penanggung insurans akan membuat bayaran terhadap bahagian
tersebut kepada penerima yang tinggal
mengikut kadar
pembahagian masing-masing.
8.
9.
7. Pemegang polisi boleh melantik dirinya sebagai pemegang

amanah tunggal aatu bersama ke atas wang polisi.
8. Wang polisi adalah dibayar berdasarkan kepada amanah dan
bukan sebahagian daripada harta pemegang polisi atau tertakluk
kepada hutangnya.
9. Pemegang polisi tidak boleh membatalkan penamaan, mengubah
atau menyerahkan hak polisi sebagai jaminan keselamatan tanpa
kebenaran pemegang amanah.
BRANCHES / CAWANGAN-CAWANGAN :
ALOR SETAR Tel: 04-731 1320 Fax: 04-731 0888 BATU PAHAT Tel: 07-432 6199 Fax: 07-432 5396 BUTTERWORTH Tel: 04-397 5085 Fax: 04-397 8226 IPOH Tel: 05-255 4097 Fax: 05-255 6020 JOHOR BAHRU
Tel: 07-238 9872 Fax: 07-238 7625 JOHOR JAYA Tel: 07-355 2970 Fax: 07-358 4754 KAJANG Tel: 03- 8737 9236 Fax: 03-8734 1467 KANGAR Tel: 04-976 8905 Fax: 04-977 3636 KEPONG Tel: 03-6257 7623
Fax: 03-6257 8249 KLANG Tel: 03-3341 0559 Fax: 03-3342 6890 KLUANG Tel: 07-772 2182 Fax: 07-773 3993 KOTA BHARU Tel: 09-748 1033 Fax: 09-744 9633 KOTA KINABALU Tel: 088-232 200 Fax: 088-232 204
KUALA LUMPUR Tel: 03-2693 2937 Fax: 03-2693 8431 KUALA TERENGGANU Tel: 09-624 6561 Fax: 09-624 6531 KUANTAN Tel: 09-566 4527 Fax: 09-566 1164 KUCHING Tel: 082-247 288 Fax: 082-422 914
MAIN BRANCH Tel: 03-7875 3333 Fax: 03-7875 3863 MELAKA Tel: 06-281 3707 Fax: 06-288 3090 MIRI Tel: 085-420 102 Fax: 085-420 924 PENANG Tel: 04-229 7181 Fax: 04-228 9191 SEGAMAT Tel: 07-932 9303
Fax: 07-932 1701 SELANGOR Tel: 03- 2148 1528 Fax: 03-2145 9949 SEREMBAN Tel: 06-767 2158 Fax: 06-763 8462 SIBU Tel: 084-348 333 Fax: 084-317 766 SITIAWAN Tel: 05-691 0515 Fax: 05-691 2341
SUNGAI PETANI Tel: 04-442 8218 Fax: 04-442 8217 TAIPING Tel: 05-807 2254 Fax: 05-808 8922 TAWAU Tel: 089-762 633 Fax: 089-762 533 TEMERLOH Tel: 09-296 0933 Fax: 09-296 6933

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UM-NM-FA13(E)

KURNIA TRAVEL SUPREME INSURANCE POLICY SCHEDULE

Agent Code & Name

Business Reg. No./ New/Old NRIC No.

Period of Insurance / Tempoh Insurans

First Country of Arrival Abroad

As per list attached

Descriptions of benefits / Faedah Deskripsi

KURNIA TRAVEL SUPREME INSURANCE POLICY SCHEDULE

Previous Policy No.

Date of Issue / Time

Issued By / Dikeluarkan Oleh

IMPORTANT NOTICE / NOTIS PENTING

Financial Mediation Bureau ( FMB )

Jabatan Konsumer Dan Amalan Pasaran

KURNIA TRAVEL SUPREME INSURANCE POLICY SCHEDULE

Nominee / Relationship / Percentage

NITHIANANTHA RAO SEKARAN

SHUBASHINI TAMIL MANIMOLI

: SARAVANAN A/L MUTTIA

COVER NOTE NO.

---------- Please bring this document during your travel -----------

Kurnia Travel Supreme

Name of Insured Person

NRIC / B.C. / Passport

For Emergency Medical Evacuation and Repatriation

+603-78415750 & +603-76283770

---------- Please bring this document during your travel -----------

---------- Please bring this document during your travel -----------

Kurnia Travel Supreme

Name of Insured Person

NRIC / B.C. / Passport

For Emergency Medical Evacuation and Repatriation

+603-78415750 & +603-76283770

---------- Please bring this document during your travel -----------

---------- Please bring this document during your travel -----------

Kurnia Travel Supreme

Name of Insured Person

NRIC / B.C. / Passport

For Emergency Medical Evacuation and Repatriation

+603-78415750 & +603-76283770

---------- Please bring this document during your travel -----------

---------- Please bring this document during your travel -----------

Kurnia Travel Supreme

Name of Insured Person

NRIC / B.C. / Passport

For Emergency Medical Evacuation and Repatriation

+603-78415750 & +603-76283770

---------- Please bring this document during your travel -----------

---------- Please bring this document during your travel -----------

Kurnia Travel Supreme

Name of Insured Person

NRIC / B.C. / Passport

For Emergency Medical Evacuation and Repatriation

+603-78415750 & +603-76283770

---------- Please bring this document during your travel -----------

---------- Please bring this document during your travel -----------

Kurnia Travel Supreme