REQUEST FOR VEHICLE TO BE UNDER COVERED

VEHICLE REGISTRATION NO:___________________________________

PERIOD OF COVER:___________________________________________
VALUE INSTRUCTED BY CUSTOMER RM
RECOMMENDED AGREED VALUE RM
RECOMMENDED SUM COVERED RM

I,…………………………………….………………….… (NRIC.No …..……………………………..……………….)

the motor certificate holder hereby confirm that, I wish to insure / renew my motor certificate at a Sum
Covered value of RM as requested by me and agreed that since the
vehicle is covered below Market Value therefore I shall bear the rateable proportion in the event of loss
arise thereof.

I am aware of the fact that this certificate is subject to Average of Under Coverage Clause – 2(c). In the
event of a claim, I am prepared to face the consequence of receiving compensation based on Under
Covered computation.

Under Certificate Clause- 2 (c):

“ If Your Vehicle is covered for a sum lower than market value, in the event of loss or damage, You
will bear the difference and the rateable proportion of the loss accordingly. This condition does not
apply unless the market value at the time of loss is more than the sum insured by 10% or more”.

Participant’s Signature Staff Signature

______________________________ ________________________
Date : Date:

Contact No_____________________ Name:__________________