Allianz General Insurance Company (Malaysia) Berhad 200601015674 (735426-V)

LEVEL 13, BLOCK 3A PLAZA SENTRAL, JALAN STESEN SENTRAL 5 KUALA LUMPUR SENTRAL 50470 KUALA LUMPUR
Tel No: 03-22633888 Fax No: 03-22633838 Email:

MOTOR PA - BIKE WARRIOR ePROPOSAL FORM

Allianz General Insurance Company (Malaysia) Berhad ("Company") is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia (BNM).
Consumer Insurance Contract :
Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for purposes unrelated to your trade, business or
profession, you have a duty to take reasonable care not to make a misrepresentation in answering the uestions in this Proposal Form and disclose any other matter that you
know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied, otherwise it may result in avoidance of contract, claim denied or
reduced, terms changed or varied, or contract terminated.
Non-Consumer Insurance Contract
Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for purposes related to your trade, business or
profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and
any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of contract, claims denied or reduced,
terms changed or varied, or contract terminated.
This duty of disclosure for Consumer and Non-Consumer Insurance Contract shall continue until the time the contract is entered into, varied or renewed.
General Important Notice :
1. You also have a duty to tell us immediately if at any time after your contract of insurancehas been entered into, varied or renewed with us, any of the information given is
inaccurate or has changed.
2. You should ensure that this Proposal Form is completed correctly as it forms the basis of the insurance contract. This basis of contract clause shall not apply if you are an
individual applying for this insurance wholly for purposes unrelated to your trade, business or profession.
3. This Proposal Form shall form part of the Policy contract. Policy owners are advised to read the policy carefully and understand its contents. You are encouraged to seek
clarification from the Company if necessary.
4. The liability of the Company does not commence until acceptance of the Proposal Form has been intimated by the Company or Policy has been issued.
5. Any policy issuance, entitlement or claims submitted arising from the insurance contract issued shall be subjected to the requirements of Economic Sanctions, Terrorism
Financing, Proliferation Financing and other UN-sanction Regimes.

eProposal No.: PBW00109092 Class 08-93-34

Account No. Period of Insurance Issuing Date / Time
SC94346 From : 09-11-2022 To : 08-11-2023 09-11-2022 / 11.11.52
PERSONAL PARTICULARS OF PROPOSER
Name of Proposer MUHAMMAD SYIMIR BIN ROZANI NRIC/Passport No. 950726106015
Date of Birth 26/07/1995
Address NO 28 LORONG SUNGAI MULIA 4, BATU 5 JALAN Age 27
GOMBAK Gender MALE
53100 KUALA LUMPUR
Marital Status MARRIED
WILAYAH PERSEKUTUAN
Nationality MALAYSIA
Designation ENTERTAINER (PROFESSIONAL /NON-
PROFESSIONAL )
Contact No. (Tel. No.) - (Fax. No.) -
(HP) 6013-9505306 (Email) -
GST Registered [ ]Yes [ / ]No Risk Located Within Malaysia
GST Reg. Date Purpose of Insurance Non Business
GST Reg. No. Sole Proprietor [ ]Yes [ / ]No

DESCRIPTION OF INTEREST INSURED : Whilst riding and/or as a pillion rider boarding or alighting from the named vehicle described below :-
REGISTRATION NO. : W1721V
CAPACITY : 647
TYPE / MAKE / MODEL : NAZA NBF 650R

COVERAGE

PRINCIPAL SUM INSURED (RM)

1.PERSONAL ACCIDENT BENEFITS
Per Person
ACCIDENTAL DEATH 20,000.00
LOSS OF BOTH HANDS OR BOTH FEET 20,000.00
LOSS OF SIGHT OF BOTH EYES 20,000.00
LOSS OF ONE EYE AND ONE HAND 20,000.00
LOSS OF ONE EYE AND ONE FOOT 20,000.00
TOTAL PARALYSIS (from neck down) 20,000.00
PERMANENT QUADRAPLEGIA (loss or permanent total loss of use of four limbs) 20,000.00
LOSS OF ONE FOOT OR ONE HAND 10,000.00
LOSS SIGHT OF ONE EYE 10,000.00
INSANITY 10,000.00
LOSS OF FOUR FINGERS AND THUMB IN ONE HAND 10,000.00
LOSS OF HEARING OF BOTH EARS 10,000.00
LOSS OF ALL TOES 4,000.00
LOSS OF SPEECH (the aggregate of all losses payable in respect of any one accident for any one person 10,000.00
shall not exceed the amount of the Principal Sum Insured as specified above)
Page 1 09-11-2022 11:11:53
 Allianz General Insurance Company (Malaysia) Berhad 200601015674 (735426-V)
LEVEL 13, BLOCK 3A PLAZA SENTRAL, JALAN STESEN SENTRAL 5 KUALA LUMPUR SENTRAL 50470 KUALA LUMPUR
Tel No: 03-22633888 Fax No: 03-22633838 Email:

PRINCIPAL SUM INSURED (RM)

1.PERSONAL ACCIDENT BENEFITS
Per Person
MEDICAL EXPENSES (any one accident) 2,000.00
BEREAVEMENT ALLOWANCE 500.00
CORRECTIVE DENTAL AND/OR COSMETIC SURGERY (to the neck or head - any one accident) 1,000.00
HOSPITAL INCOME BENEFIT (up to maximum of 60 days) 50.00
DOUBLE INDEMNITY 40,000.00
RENEWAL BONUS % / AMOUNT 0.00 / 0.00

2. BIKE ASSISTANCE PROGRAM

(a) 24-Hour Emergency Towing

(b) Minor Roadside Repair

(c) Taxi and Car Rental Assistance

(d) Arrangement for Hotel Accomodation

(e) International Assistance

(f) Arrangement for Emergency Evacuation

(g) Refferal to Service Centre

(h) Emergency Message Transmission

3. ADDITIONAL BENEFITS

(a) Compassionate Cover

Pays 10 % of the sum insured of named vehicle
In the event of total loss or theft claim to the named vehicle subject to maximum of RM3,000.00

(b) Flood Cover

Pays up to RM1,500.00
In the event of damage due to flood to the named vehicle
PLAN COVERAGE

Plan BIKE WARRIOR PLAN 1

Premium (RM) 140.00

Service Tax 8.40

Note: Please add RM 10:00 for Stamp Duty 10.00

TERRITORIAL LIMITS: 1) Personal Accident Benefits 2) Bike Assistance Benefits

Malaysia, Singapore, Brunei and Thailand.
Peninsular Malaysia excluding the Islands except for Penang
and Langkawi. In East Malaysia, the towing services shall
only be available within 25km radius of Kota Kinabalu,
Sandakan, Lahad Datu, Tawau, Sibu, Bintulu, Miri, Kuching
and on the island of Labuan.

3) Compassionate Cover Benefit

Within Malaysia, Singapore, Brunei and Thailand.

DATA PRIVACY AND DISCLOSURE OF PERSONAL INFORMATION

Protection of your privacy is very important to us. Please visit our Website at http://www.allianz.com.my to view our Privacy Statement (NOTICE TO
CUSTOMERS OF ALLIANZ GENERAL INSURANCE COMPANY (MALAYSIA) BERHAD ON THE PERSONAL DATA PROTECTION ACT 2010 ).
Disclosure & Consent
The personal data you supply as an individual to purchase the above insurance will be used by the Allianz Group and it agents to facilitate the
performance of our function as an insurance company accordingly to our Privacy Statement. By signing on this proposal form You consent to the use of
Your personal data for the purposes as stated in our Privacy Statement.

GOODS AND SERVICES TAX (GST) NOTICE

You are advised to review the adequacy of your Sum Insured as Goods and Services Tax ('GST') may have an impact on your claims settlement as
stated below.

GOODS AND SERVICES TAX IMPACT ON CLAIMS SETTLEMENT

Claims settlement

Page 2 09-11-2022 11:11:53

 Allianz General Insurance Company (Malaysia) Berhad 200601015674 (735426-V)
LEVEL 13, BLOCK 3A PLAZA SENTRAL, JALAN STESEN SENTRAL 5 KUALA LUMPUR SENTRAL 50470 KUALA LUMPUR
Tel No: 03-22633888 Fax No: 03-22633838 Email:

We will pay your claim inclusive of the Goods and Services Tax on items which are taxable supplies, up to the limit of the Sum Insured.In the event that
you are entitled to claim for the Input Tax Credit and if we make a payment under this policy as compensation to you, we will reduce the amount of the
payment by deducting your Input Tax Credit entitlement irrespective of whether you have not claimed the Input Tax Credit, up to the limit of the Sum
Insured.

DECLARATION

I / We hereby declare that I / We have fully and accurately answered the questions in this Proposal Form. I agree to accept the company’s policy subject
to the terms and conditions contained therein or endorsed thereon.

Signature of Proposer : Date :

NOTE: Where the Insured Person is a child aged below 18 years, this Proposal must be signed by his/her parent/guardian.

Page 3 09-11-2022 11:11:53