INSURED INSTRUCTION NOTICE

INSURED NAME :
POLICY NO. :
VEHICLE REGISTRATION NO. :
PERIOD OF INSURANCE :
ENDORSEMENT EFFECTIVE DATE :

With reference to the above matter, I/We would be most grateful if you could effect the following:
( ) Issue a NCD Confirmation Letter (Local / Overseas)
( ) Withdraw NCD entitlement from the above mentioned policy w.e.f.
( ) Transfer the rights and benefits of my policy to w.e.f.
( ) Extend the insurance period until
( ) Cancel the above mentioned policy w.e.f ________________________ (Reason: _____________________)
( ) Amend : a) Insured’s name ____________________________ b) Vehicle No. _________________________
c) Year of Make ______________________________ d) Engine / Chasis No. __________________
e) C.C. / Tonnage ____________________________ f) Others (please specify) ________________
( ) *Increased Sum insured ( )*Decreased Sum Insured
( ) **Conversion from Third Party / Third Party Fire & Theft to Comprehensive cover
Inclusive of Extension Benefit :
( ) **Windscreen RM ( ) LLP ( ) All Riders / Drivers
( ) SRCC ( ) **Flood ( ) LLAP
( ) Thailand Extension ( ) Other ( please specify)
For your attention, I enclose herewith the :
( ) Original Policy ( ) Photocopy of I/C
( ) Original Certificate of Insurance ( ) Photocopy of Registration Card / Road Tax Disc
I/We, hereby authorized I/C No to collect the NCD
letter on my/our behalf.
Thanking you for your kind co-operation.

DECLARATION OF LOSS OF CERTIFICATE OF INSURANCE

In compliance with Road Transport Act 1987, I/We hereby declare that the Certificate of Insurance issued to me/us under
the above policy number has been lost or mislaid and this statement is true to the best of my/our knowledge.

I/We further assume responsibility for any claim or dispute arising out of the lost Certificate and undertake to indemnify the
Company in this respect.

Yours faithfully

………………………………. ……………………………….
(Signature of Insured) Company Stamp
I/C No. (If insured is a company)
* Increased and Decreased Sum Insured please attached with form Appendix 1 (Declaration of Vehicle Condition)
** Conversion from T/Party to Comprehensive and midterm inclusion of extra benefit please attached with form Appendix2 (Vehicle
Inspection Form)

Liberty General Insurance Berhad 197801007153 (44191-P)

Formerly known as AmGeneral Insurance Berhad
Corporate Tower 9, Level 13A, Pavilion Damansara Heights, 3 Jalan Damanlela, 50490 Kuala Lumpur, Malaysia.
P. O. Box 6120 Pudu, 55916 Kuala Lumpur, Malaysia.
0923

Tel: 1 800 88 3833 Email: customer@kurnia.com Web: www.kurnia.com (Service Tax Registration No.: B16-1808-31015443)