INSURED COPY (ORIGINAL)

SALINAN PEMUNYA (ASAL)

MOTOR ENDORSEMENT SCHEDULE

JADUAL PENGENDORSAN MOTOR
Insured / Policy Holder : NOOR AZRINA BINTI MAZLAN
Yang Diinsuranskan / Pemegang Polisi

Correspondence Address : NO. 891, FASA 2J, BANDAR BARU

Alamat Surat Menyurat 32040 SERI MANJONG
PERAK

Policy No. : 18VJB0023810-05 Product : PRIVATE CAR EXCLUDING GOODS

No. Polisi Produk POLICY
Endorsement No. : 18VJB0023810-05*001
No. Pengendorsan
Issue Date : 29/04/2024
- Tarikh Dikeluarkan -
Account No. : JB08525 /J+A
No. Akaun
Endorsement Effective Date : 29/04/2024
Tarikh Kuatkuasa Pengendorsan
Period of Insurance : From 27/09/2023 to 26/09/2024
Tempoh Insurans Dari Hingga
Vehicle Registration No. : AJR8918
No. Pendaftaran kenderaan

RM
Additional Premium : 240.30
Premium Dikembalikan

Transfer Fees : 0.00

Bayaran Pemindahan

Service Tax : 19.22

Cukai Perkhidmatan

Rebate/Discount : 0.00
Rebat/Diskaun

Total Additional Premium : 259.52

Jumlah Premium Tambahan

Total Payable (Rounded) : 259.50

Jumlah Yang Perlu Dibayar (Dibundarkan)

Act Premium : 112.28

Premium Akta

Description
Keterangan

NO CLAIM DISCOUNT (NCD) WITHDRAWAL

IT IS HEREBY DECLARED AND AGREED THAT EFFECTIVE 29/04/2024 THE NO CLAIM DISCOUNT OF 55 % UNDER THIS POLICY IS
WITHDRAWN.
IN CONSIDERATION OF THE ABOVE, AN ADDITIONAL PREMIUM OF RM259.52 IS HEREBY CHARGED TO THE INSURED.
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.

NB: This Endorsement is to be attached to the Policy and to be subject to terms, exceptions and condition thereof unless otherwise
or they may expressly varied hereby

Subject otherwise to the terms, exceptions and conditions of this Policy

Tertakluk kepada terma-terma, pengecualian-pengecualian dan syarat-syarat Polisi ini

Date : 29/04/2024
Tarikh ALLIANZ GENERAL INSURANCE COMPANY (MALAYSIA) BERHAD (200601015674)

Authorised Signature

OPUS-2308525-019402861-1 PAGE: 1
INSURED COPY (ORIGINAL)
SALINAN PEMUNYA (ASAL)

PREMIUM DEBIT NOTE

Nota Debit Premium

Insured / Policy Holder : NOOR AZRINA BINTI MAZLAN

Yang Diinsuranskan / Pemegang Polisi NO. 891, FASA 2J, BANDAR BARU
32040 SERI MANJONG
PERAK

Policy No. : 18VJB0023810-05 Product : PRIVATE CAR EXCLUDING

No. Polisi Produk

Account No. : JB08525 /J+A Debit Note No. : D18VJB0023810-05*001

No. Akaun No. Nota Debit

Issue Date : 29/04/2024

Tarikh Dikeluarkan

Particulars Amount (RM)

Butiran Amaun (RM)

TO PREMIUM DUE ON : 240.30

UNTUK PREMIUM YANG PERLU
DIBAYAR PADA
PERIOD FROM 27/09/2023 To 26/09/2024

240.30

ADD : Service Tax 19.22

TAMBAH

Total Premium 259.52

Jumlah Premium

Amount Payable (Rounded) 259.50

Jumlah Yang Perlu Dibayar (Digenapkan)
INSURED COPY (ORIGINAL)
SALINAN PEMUNYA (ASAL)

DEBIT NOTE
NOTA DEBIT

Policy No. : 18VJB0023810-05 Product : PRIVATE CAR EXCLUDING GOODS

No. Polisi Produk POLICY
Account No. : JB08525
No. Akaun Debit Note No. : STDN23092000003864
No. Nota Debit
Insured / Policy Holder : NOOR AZRINA BINTI MAZLAN
Yang Diinsuranskan / Pemegang NO. 891, FASA 2J, BANDAR BARU Debit Note Date : 29/04/2024
Polisi Tarikh Nota Debit
32040 SERI MANJONG
PERAK

Period of Insurance : From 27/09/2023 To 26/09/2024

Tempoh Insurans

Item No. Description Total Amount (RM)

No. Item Keterangan Jumlah (RM)

Gross Premium 240.30

Rebate 0.00
Stamp Duty 0.00

240.30
Adjustment on (tax) invoice no. STAX23092000083482 dated 06/09/2023 being NCD WITHDRAW
via Endorsement No. 18VJB0023810-05*001

Premium 240.30

240.30

Premium Payable Excluding Service Tax 240.30

Premium Subject to Service Tax at 8% 240.30

( Period of Insurance : 27/09/2023 - 26/09/2024 )

Service Tax Payable 19.22

Total Premium Payable (including Service Tax and Stamp Duty) 259.52

Total Amount Payable (including Service Tax and Stamp Duty) (Rounded) 259.50

Allianz General Insurance Company (Malaysia) Berhad

This is computer generated. No signature is required.
INSURED COPY (ORIGINAL)
SALINAN PEMUNYA (ASAL)

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