2/20/23, 9:45 AM Cover note

ORIGINAL JPJ Ref (Cover Note) Number X771408

AXA Policy Ref No: VMX/79727043/11/02/BBB*
AXA AFFIN GENERAL INSURANCE BERHAD (197501002042)
(Approved Insurers) New Business
Ground Floor, Wisma Boustead,
71 Jalan Raja Chulan
50200 Kuala Lumpur Malaysia
Tel :(603) 21708282 Fax: (603) 20317282  
Internet: http://www.axa.com.my
Service Tax Reg No: W10-1808-31015017

 
Intermediary: 37749

Road Transport Act 1987 (Malaysia)

The Motor Vehicles (Third Party Risks) Rules 1959 (Malaysia)
The Motor Vehicles (Third Party Risks and Compensation) Act (Cap 189) Republic of Singapore
The Motor Vehicles (Third Party Risks and Compensation) Rules, 1960 Republic of Singapore
The Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam

CBC REGULATION -Section 84(1) of the Financial Services Act 2013:

No licensed insurer shall assume any risk in respect of such description of policy as may be prescribed by the Bank unless and until the premium payable is
received by the licensed insurer in such manner and within such time as may be prescribed by the Bank.
Name AZLAN INSANI BIN DERAHMAN Date 20-02-2023
Serv.T Reg. No.
I/C No.(New/Business Regn) 741024-03-5143 
SIMPANG TIGA PEROL 
JALAN KUALA KRAI 
Address KOTA BHARU 
16010  KOTA BHARU
KELANTAN
having proposed for insurance and paid the premium in respect of the Motor Vehicle described in the Schedule below the risk is hereby HELD COVERED in the
terms of the Company's usual form of Motorcycle - Private Use [tp] Policy applicable thereto for the period from 7:17 AM   on 20/02/2023   to Midnight on
19/02/2024  unless the cover be terminated by the Company by notice in writing in which case the insurance will thereupon cease and the Company will return a
proportionate part of the premium already collected for such insurance after the allowance for the period the Company has been on risk.

SCHEDULE
Renewal of Policy No : Log Book No. : C1T7WDMN
Make /Model of Vehicle : HONDA WAVE Sum Insured : RM 0.00
Vehicle Registration Number : PNW2178 Excess : RM 0.00
Cubic Capacity or H.P. or Tonnage : 125 CC Use of Vehicle : MOTORCYCLE
USE
- PRIVATE

Year of Manufacture : 2019 Seating Capacity including

Driver :5
Engine Number : JC60E2406668
Chassis Number : PMKJC6060KB404055 Premium : RM 93.73
Hire Purchase/Leasing/Employer's Company or Government loan or other: NIL
Additional Coverage
: Premium Payable (rounded) : RM 93.75
Named Drivers :

I/We hereby certify that this Covering Note is issued in accordance with the provision of Part IV of the Road Transport Act 1987 (Malaysia). The Motor Vehicles
(Third Party Risks and Compensation) Act (Cap 189) Republic of Singapore and The Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei
Darussalam.
Remarks: AXA AFFIN GENERAL INSURANCE BERHAD (197501002042)
Current NCD allowed: 15.00 % - AXA (Approved Insurers)
Previous NCD: 0.00 % - (POLICY NO. - TAKAFUL NASIONAL SDN
BERHAD) This is a system generated document. No signature is required.
24-hours Motor Assist Hotline (Breakdown and Accident) for Private Motor
Comprehensive policyholder : 1-800-88-1033
Issued by mk37749 on 20-02-2023

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