1 September 2023

Dear Valued Customer,

AmGeneral Insurance Berhad is now Liberty General Insurance Berhad

We are excited to announce that AmGeneral Insurance Berhad (“AmGeneral”) changed its corporate name
to Liberty General Insurance Berhad and forthwith, our corporate profile and documents will showcase
the new corporate name with inclusion of “formerly known as AmGeneral insurance Berhad” as required
by regulatory. Changes to other documents and brand assets will be made gradually.

In July 2022, Liberty Mutual completed its acquisition of AmGeneral after receiving regulatory approval.
On 31 March 2023, pursuant to a Court Order issued by the High Court of Malaya, business transfer from
Liberty Global Holdings Sdn Bhd (formerly known as Liberty Insurance Berhad) (“LGHSB”) to AmGeneral
was concluded. Currently, AmGeneral is a wholly owned subsidiary of LGHSB and through LGHSB, Liberty
Mutual Group and AmGeneral Holdings Berhad has 70% and 30% interest respectively in AmGeneral.

Same policy, benefits and services—with a new name!

We would like to assure you that the benefits and terms of your insurance policies with us will not be
affected as we undergo the name change. All customers’ insurance policies, rights, and obligations under
AmGeneral will remain unchanged.

As a leading general insurer in Malaysia and a member of Liberty Mutual Group, we are committed to
create a stronger and experienced team to serve you better and provide best-in-class customer experience.

Through this merger, our combined businesses will bring together more than 3 million customers along
with more than 8,000 agents and partners; and we will operate under our three retail brands – Liberty
Insurance, Kurnia Insurans and AmAssurance, catering for different segments of customers and partners.

Our customers are at the heart of our business. We aspire to continue to grow STRONGER TOGETHER,
recognizing the best in both of our business practices and leveraging on global capabilities and expertise.

Thank you!
We want to take this opportunity to thank you for your trust and bringing us to where we are today. If you
have any query on the merger, feel free to reach out to us via the same contact details or you can scan the
QR Code below to contact our Customer Contact Center.

We look forward to your continuous support.

Warm regards,

Puneet Pasricha
www.libertyinsurance.com.my
Chief Executive Officer

Liberty General Insurance Berhad 197801007153 (44191-P)

Formerly known as AmGeneral Insurance Berhad

Liberty Insurance Tower, CT9, Pavilion Damansara Heights, 3, Jalan Damanlela, Pusat Bandar Damansara, 50490 Kuala Lumpur.
P.O. Box 6120 Pudu, 55916 Kuala Lumpur.
Tel: +603 2268 3333 Fax: +603 2268 2222 Website: www.libertyinsurance.com.my
(Service Tax Registration No.: B16-1808-31015443)
 1 September 2023

Kepada pelanggan yang dihormati,

AmGeneral Insurance Berhad kini adalah Liberty General Insurance Berhad

Kami sangat berbesar hati untuk mengumumkan bahawa AmGeneral Insurance Berhad (“AmGeneral”) telah
menukar nama korporatnya kepada Liberty General Insurance Berhad dan berikutan pertukaran nama korporat
tersebut, profil korporat dan dokumen kami akan mempamerkan nama korporat baru berserta pernyataan
“dahulunya dikenali sebagai AmGeneral Insurance Berhad” seperti yang dikehendaki oleh peraturan undang-
undang. Perubahan kepada dokumen lain dan asset jenama akan dilakukan secara berperingkat.

Pada Julai 2022, Liberty Mutual telah menerima kelulusan daripada pihak berkuasa untuk mengambil alih
syarikat AmGeneral. Pada 31 Mac 2023, menerusi Perintah Mahkamah yang dikeluarkan oleh Mahkamah Tinggi
Malaysia, pemindahan perniagaan daripada Liberty Global Holdings Sdn Bhd (dahulunya dikenali sebagai Liberty
Insurance Berhad”) (“LGHSB”) kepada AmGeneral telah dimuktamadkan. AmGeneral kini adalah anak syarikat
milik penuh LGHSB dan melalui LGHSB, Liberty Mutual Group dan AmGeneral Holdings Berhad masing-masing
mempunyai 70% dan 30% kepentingan dalam AmGeneral.

Polisi, faedah dan perkhidmatan yang sama—dengan nama baharu!

Kami memberi jaminan bahawa penukaran nama ini tidak akan sama sekali menjejaskan manfaat dan terma
polisi insurans anda dengan kami. Semua polisi insurans, hak serta kewajipan pelanggan AmGeneral akan kekal
tanpa sebarang perubahan.

Sebagai syarikat insurans am terkemuka di Malaysia dan ahli Kumpulan Liberty Mutual, kami amat komited
untuk mewujudkan tenaga kerja yang lebih teguh dan berpengalaman untuk memberikan khidmat pelanggan
yang terbaik untuk anda.

Melalui penggabungan ini, syarikat kami mempunyai lebih daripada 3 juta pelanggan serta 8,000 ejen dan rakan
kongsi; dan kami akan beroperasi melalui tiga jenama- Liberty Insurance, Kurnia Insurans dan AmAssurance,
untuk memenuhi keperluan segmen pelanggan dan rakan kongsi yang berbeza.

Pelanggan kami adalah nadi perniagaan kami. Kami berazam untuk terus berkembang LEBIH TEGUH BERSAMA,
mengenal pasti dan mempraktikkan cara kerja yang terbaik daripada kedua-dua perniagaan yang telah
digabungkan dengan memanfaatkan keupayaan dan kepakaran global.

Terima kasih!
Kami mengambil kesempatan ini untuk mengucapkan terima kasih di atas kepercayaan anda kepada kami
selama ini. Jika anda mempunyai sebarang pertanyaan tentang penggabungan ini, sila hubungi kami menerusi
talian yang sedia ada atau sila imbas Kod QR seperti di bawah untuk menghubungi Khidmat Pelanggan kami.

Terima kasih kerana terus menyokong kami.

Yang benar,

Puneet Pasricha
Ketua Pengawai Eksekutif www.libertyinsurance.com.my

Liberty General Insurance Berhad 197801007153 (44191-P)

Formerly known as AmGeneral Insurance Berhad

Liberty Insurance Tower, CT9, Pavilion Damansara Heights, 3, Jalan Damanlela, Pusat Bandar Damansara, 50490 Kuala Lumpur.
P.O. Box 6120 Pudu, 55916 Kuala Lumpur.
Tel: +603 2268 3333 Fax: +603 2268 2222 Website: www.libertyinsurance.com.my
(Service Tax Registration No.: B16-1808-31015443)
 UW-PW-S009(E)(MT)
REV: B
RTD Code:08
PRIVATE CAR EX GOODS
"Please call KAA Toll Free 1 800 88 3833 for breakdown or accident assistance" M.X.1

PRIVATE CAR SCHEDULE / JADUAL KERETA PERSENDIRIAN

auto365 Comprehensive Plus
The Insured / Pemegang Polisi Policy No. / No. Polisi
JVE3755410 01-C2
NUR HAFIZAH BINTI FHAUDZI
Account No. / No . Akaun
T58300-00
NO 105 LALUAN 4 Type of Cover / Jenis Perlindungan
TAMAN MANJUNG BARU COMPREHENSIVE PLUS
32040 SERI MANJONG Period of Insurance / Tempoh Insurans
From / Dari 00:00:01 AM 30-01-2023 To / Hingga 29-01-2024
Occupation / Pekerjaan Bus. Regn. No / Premium / Premium RM 726.15
No Pendaftaran Perniagaan All Rider / Semua Penunggang 0.00
NURSE
-
I.C. No. / No.Kad Pengenalan NCD / Diskaun Tanpa Tuntutan 0.00% 0.00
910802115022 Wef / Berkuatkuasa dari 30-01-2023
726.15
Hire Purchase Owner / Pemilik Sewa Beli Optional Cover
- Compensation For Assessed Repair Time (CART) RM 100 per T 140.00
day up to 14 days / Pampasan untuk Tempoh Pembaikan T
Make & Type of Body / Buatan & Jenis Badan yang DianggarkanRM 100 sehari sehingga 14 hariT

PERODUA KELISA EZ / 4D HATCHBACK Windscreen Damage (Tempered/Laminated Glass Inclusive T 120.00

Labour Cost) / Kerosakan Cermin Kenderaan (Pengubahan T
Registration No. / Excess / Lebihan Regn. Card No. / No.Kad Cermin / Cermin Berlapis Termasuk Kos Buruh) RM 800.00T
No.Pendaftaran Pendaftaran T
0.00 Gross Premium / Premium Kasar 986.15
PFD1969 -

Carrying or Seating Tonnage / C.C./ Watt Sum Insured / Jumlah Service Tax / Cukai Perkhidmatan 6% 59.17
Capacity Incl. Driver / Tan / Keupayaan Enjin Stamp Duty / Duti Setem 10.00
Diinsuranskan (RM)
Muatan Tempat Duduk 989.00 CC
Termasuk Pemandu 10,000.00
Year of Manufacture /
5 Tahun Diperbuat (Agreed Value)
2002

Engine/Motor No. / No. Enjin/Motor

B016609
Chassis No. / No. Casis Trailer / Treler
PM2L701S002016627 -
Only The Extensions, Endorsement And / Or Warranties Indicated Below Apply To
This Policy. / Hanya Lanjutan, Endorsemen dan / atau Warranti sepertimana yang
dinyatakan di bawah ini boleh diguna pakai dalam polisi ini.
2, 89, 112, 87 (AGREED VALUE)

Total Due / Jumlah Berbayar RM 1,055.32

Subject to IMPORTANT NOTICE:Your duty as the Owner of the vehicle as attached. Total Due (OTC) / Jumlah Berbayar Di Kaunter RM 1,055.30
Named Driver / Pemandu Yang Dinamakan
ANY AUTHORISED DRIVER

Geographical Areaa : Malaysia , Republic of Singapore and Negara Brunei Darussalam. / Kawasan Geografi : Malaysia, Republik Singapura dan
Negara Brunei Darussalam.
Limitations as to Use / Authorised Driver : As described in the Certificate of Insurance. / Had Penggunaan / Pemandu Yang Diberi Kuasa : Seperti
yang tercatat dalam Sijil Insurans.
Replacing Cover Note No./ - Issued By / Dikeluarkan Oleh : For / untuk
Gantian No. Nota RANCAK JAYA AGENCY Liberty General Insurance Berhad
Perlindungan NO 47 JALAN SEROM BARU 1
Renewal of Policy No./ - TAMAN SEROM BARU, SUNGAI MATI
Pembaharuan No.Polisi 84400 TANGKAK
Date of Proposal or 29-01-2023 JOHOR
Declaration / Tel :
Tarikh Cadangan atau Fax :
Pengisytiharan Authorised Signature /
Tandatangan Yang Diberi Kuasa
Date of Issue / Time 29-01-2023 10:25:09 AM
Tarikh Dikeluarkan / Waktu
Note: / Nota: No refund of premium for any cancellation of policy if premium is charged on minimum premium / Tiada bayaran balik premium bagi sebarang pembatalan polisi sekiranya
premium yang dikenakan adalah premium minima.
The benefit(s) payable under this eligible policy is protected by PIDM up to limits. Please refer to PIDM’s TIPS Brochure or contact Liberty General Insurance Berhad or PIDM (visit
www.pidm.gov.my). / Manfaat-manfaat yang dibayar di bawah polisi yang layak ini adalah dilindungi oleh PIDM sehingga had perlindungan. Sila rujuk Brosur Sistem Perlindungan
Manfaat Takaful dan Insurans PIDM atau hubungi Liberty General Insurance Berhad atau PIDM (layari www.pidm.gov.my). 10JVB0PM910109-4

Page 1 28-12-2023 11:43:01 AM

 Policy Document No./ UW-PW-S009(E)(MT)
No.Dokumen Polisi: REV: B
C.I. Code / M.X.1
Kod Sijil Insurans:

CERTIFICATE OF INSURANCE / SIJIL INSURANS

AKTA PENGANGKUTAN JALAN RAYA 1987 (MALAYSIA)
PERATURAN KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA) 1959 (MALAYSIA)
RTD Code :08
ORIGINAL COPY / AKTA KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA DAN PAMPASAN) (KAP 189) REPUBLIK SINGAPURA
PERATURAN KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA DAN PAMPASAN 1960 (REPUBLIK SINGAPURA)
SALINAN ASAL AKTA INSURANS KENDERAAN BERMOTOR (RISIKO KEATAS PIHAK KETIGA) (KAP 90) NEGARA BRUNEI DARUSSALAM
Certificate No. / No. Sijil
JVE3755410 01-C2 Excess : RM 0.00 Sum Insured : RM 10,000.00 (Agreed Value)
1. Index Mark and Registration Number of Vehicle / Tanda Indeks dan No. Pendaftaran Kenderaan
PFD1969 NCD : 0.00% Wef : 30-01-2023
2. Name of Policyholder / Nama Pemegang Polisi
NUR HAFIZAH BINTI FHAUDZI
3. Period of Insurance / Tarikh Insurans
From / Dari 00:00:01 AM 30-01-2023 To / Hingga 29-01-2024
4. Persons or Classes of Persons entitled to drive / Orang atau kelas orang yang layak memandu:*
a) The Policyholder.
b) Any other person who is driving on the Policyholder's order or with his/her permission.
a) Pemegang Polisi.
b) Sesiapa yang memandu atas arahan Pemegang Polisi atau dengan kebenarannya.
Provided that the person driving is permitted in accordance with the licensing or other laws or regulations to drive the motor vehicle or has been so
permitted and is not disqualified by order of a Court of Law or by reason of any enactment or regulation in that behalf from driving the motor vehicle.
Dengan syarat orang yang dibenarkan memandu itu menurut perlesenan atau undang-undang atau peraturan lain bagi memandu kenderaan bermotor
dan telah dibenarkan dan tidak hilang kelayakan atas perintah Mahkamah Undang-undang atau atas sebab mana-mana enakmen atau peraturan
berkenaan pemanduan kenderaan bermotor.
5. Limitations as to use / Had Penggunaan*
Use only for social, domestic and pleasure purposes and for the insured`s business. The policy does not cover :-
Use for hire or reward, racing, pace-making, reliability trial, speed-testing the carriage of goods other than samples in connection with any trade or business.
Digunakan hanya untuk tujuan sosial, domestik dan persiaran dan untuk perniagaan Pemegang Polisi.
Polisi ini tidak melindungi kegunaan untuk sewaan atau ganjaran, perlumbaan, mengkadar kelajuan, ujian kebolehpercayaan, ujian kelajuan, membawa barangan
selain daripada sampel yang berkaitan dengan apa-apa pekerjaan atau perniagaan
*Limitations rendered inoperative by Section 95 of the Road Transport Act 1987 (Malaysia) or Section 8 of the Motor Vehicles (Third Party Risks and
Compensation) Act (Cap 189) Republic of Singapore or Section 7 of the Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei
Darussalam are not included under this heading.
*Had yang ditakwilkan tidak berkuatkuasa oleh Seksyen 95 Akta Pengangkutan Jalanraya (Malaysia),1987 atau Seksyen 8 Akta Kenderaan Bermotor
(Risiko Keatas Pihak Ketiga Dan Pampasan) (Kap 189) Republik Singapura dan Seksyen 7 Akta Insurans Kenderaan Bermotor (Risiko Keatas Pihak
Ketiga) (Kap 90) Negara Brunei Darussalam tidak termasuk dibawah tajuk ini.
I/WE HEREBY CERTIFY that the policy to which this certificate relates is issued in accordance with the provisions of Part IV of the Road Transport
Act,1987 (Malaysia),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. /SAYA / KAMI DENGAN INI MENGESAHKAN bahawa polisi yang melaluinya sijil ini dikeluarkan
adalah selaras dengan peruntukan Bahagian IV Akta Pengangkutan Jalan, 1987 (Malaysia), Akta Kenderaan Bermotor (Risiko Keatas Pihak Ketiga dan
Pampasan) (Kap 189) Republik Singapura dan Akta Insurans Kenderaan Bermotor (Risiko Keatas Pihak Ketiga) (Kap 90) Negara Brunei Darussalam.
IMPORTANT NOTICE: Your duty as the Owner of the vehicle. Failure to comply to the below
may result your claim to be declined . For / untuk
(1) The insured will have to take all reasonable care to secure the vehicle from loss or damage.
(2) Report to the police for all incidents. For road accident, you have to report to the police within 24 hours. Liberty General Insurance Berhad
(3) Notify us in writing within 7 days after the incident and complete the claim form in full and return it to us (Incorporated in Malaysia / Ditubuhkan di Malaysia)
with the related documents within 21 days from your notification's date.
(4) You must obtain our consent in writing before you repair your vehicle or incur any expenses.
Approved Insurers / Penanggung Insurans Yang Dibenarkan
(5) For private car own damage claim - In the event of claim, repairs must be conducted by our
approved repairer.
(6) When incident happen, you need to collect these details :
(a) all drivers e.g full name, residential address and contact number
(b) all vehicles e.g. make and model, registration number, and insurance details
(c) date, time and location of the incident
(d) description of the incident and
(e) report to us immediately
(f) report to us for any claims made by another person against you and send us the notices and
letters within 14 days from the receipt of the documents. Authorised Signature /Tandatangan Yang Diberi Kuasa
(7) Do not negotiate or settle any claims made against you, unless you have our consent in writing.
(8) We will have full discretion in the conduct, defence and/or settlement of any claim.
Agent Code / Kod Ejen: T58300-00
N.B. (i) We have the right to cancel this policy by giving you 14 days’ notice in writing by
registered post to your last known address in our records.
(ii) Betterment – In the event your vehicle age is 5 years and above, this policy is subject to rate of betterment .
(iii) You need to read this policy carefully, and if any error or incorrect description is found herein, or
if the cover is not in accordance with your wishes, you should inform us immediately and return this policy to us for
alteration.

The benefit(s) payable under this eligible policy is protected by PIDM up to limits. Please refer to PIDM’s TIPS Brochure or contact Liberty General Insurance Berhad or PIDM (visit
www.pidm.gov.my). / Manfaat-manfaat yang dibayar di bawah polisi yang layak ini adalah dilindungi oleh PIDM sehingga had perlindungan. Sila rujuk Brosur Sistem Perlindungan Manfaat
Takaful dan Insurans PIDM atau hubungi Liberty General Insurance Berhad atau PIDM (layari www.pidm.gov.my).

Important Notice / Kenyataan Penting :

• For environmental conservation, we have adopted paper less printing concept.Please log on to our website to view the Bahasa Malaysia language policy wordings,terms and conditions and exclusion.
For further enquiries, please contact your insurance intermediary or our Customer Contact Centre. / Untuk pemeliharaan alam sekitar, kami telah mengaplikasikan konsep tanpa percetakan. Sila layari
laman web kami untuk rujukan kandungan polisi,terma-terma,syarat-syarat dan pengecualian-pengecualian dalam Bahasa Melayu.Untuk pertanyaan lanjut, sila hubungi ejen insurans anda atau Pusat
Khidmat Pelanggan kami.
• You are advised to read and understand the summary of this product as contained in the Product Disclosure Sheet on our website. / Anda dinasihati supaya membaca dan memahami ringkasan produk
ini seperti yang tertera di dalam Lampiran Pemberitahuan Produk yang boleh didapati dilaman web kami.
0917

Page 2 28-12-2023 11:43:01 AM

 Invoice
Invois
COPY

Invoice No. : SST-01-23-11758257 Date : 29-01-2023

No. Invois Tarikh

Name : NUR HAFIZAH BINTI FHAUDZI

Nama

Address : NO 105 LALUAN 4

Alamat TAMAN MANJUNG BARU
32040 - SERI MANJONG

Agent Name : RANCAK JAYA AGENCY Account No. : T58300-00

Nama Agen No. Akaun

Policy/Endorsement No. : - Cover Note No. : JVE3755410

No. Polisi/Endorsemen No. Nota

Class of Policy : PRIVATE CAR EX GOODS

Jenis Insurans

Period of Insurance : From 30-01-2023 To 29-01-2024

Tempoh Insurans

No. Description Total (RM)

1 Gross Premium / Premium Kasar 986.15
2 Service Tax / Cukai Perkhidmatan 6% 59.17
3 Stamp Duty / Duti Setem 10.00
4 Total Payable (OTC) / Jumlah Berbayar Di Kaunter 1,055.30
5 Total Payable / Jumlah Berbayar 1,055.32

This is computer generated. No signature is required.

Ini adalah cetakan computer. Tandatangan tidak diperlukan.

Page 3 28-12-2023 11:43:01 AM

INSURED NAME : NUR HAFIZAH BINTI FHAUDZI

VEHICLE NO : PFD1969
COVER NOTE NO : JVE3755410

PRIVACY CLAUSE
1.0 PRIVACY CLAUSE

1.1 You confirm that you have read, understood and agree to be bound by the Privacy Notice of Liberty General
Insurance Berhad (hereinafter referred to as “the Company”) which is available at our website and the clauses
herein, as may relate to the processing of your personal information. For the avoidance of doubt, you agree that
the said Privacy Notice shall be deemed to be incorporated by reference into this Insurance Policy.
1.2 In the event you provide personal and/or financial information relating to third parties, including information relating
to your next-of-kin and dependents, for the purpose of operating the Insurance Policy with the Company or
otherwise subscribing to the Company's products and services, you:

a. confirm that you have obtained their consent or are otherwise entitled to provide the information to the
Company and for the Company to use it in accordance with this Insurance Policy;

b. agree to ensure that the personal and financial information of the said third parties is accurate and
update the Company in writing in the event of any change to the said personal and financial
information; and
c. agree to the Company's right to terminate the Insurance Policy should such consent be withdrawn by
any of the said third parties
1.3 You do not agree that the Company and its related companies may contact you about products and services and
offers, which the Company and its related companies believe may be of interest to you, through various channels
of communication.
1.4 In the event you wish to consent to use your personal data to receive marketing of products and services by the
Company and its related companies, you may contact the Company as per below details or you may contact the
Company's nearest branch to you:
Customer Service Executive, Customer Contact Centre
Telephone No E-Mail
AmAssurance 1 800 88 6333 customer@amassurance.com.my
Kurnia Insurans 1 800 88 3833 customer@kurnia.com

1.5 The Company reserves the right to amend this Section from time to time at the Company's sole discretion by
providing notice to you.
VEHICLE INSURED VALUE
1.0 IF YOUR POLICY IS AN 'AGREED VALUE' POLICY
1.1 Your vehicle is insured based on an agreed value.
1.2 In the event of total loss or theft, the maximum amount that we will pay is up to the sum insured as shown in the
schedule.
2.0 IF YOUR POLICY IS A 'MARKET VALUE' POLICY
2.1 Your vehicle is insured based on market value.
2.2 In the event of total loss or theft, the maximum amount that we will pay is up to the market value of the vehicle
which will be determined at the time of loss or the sum insured as shown in the schedule; whichever is lesser.

2.3 It is important to insure your vehicle with the appropriate market value. Below are the effects of over-insurance and
under-insurance when an incident happens and giving rise to a claim:
a. Over-insurance : When a claim arises, the maximum amount that we will pay you is up to the market
value of your vehicle even if your vehicle's sum insured is higher than the market
value.
b. Under-insurance : When claim arises, we will only bear part of the loss in proportion to the difference
between the market value and the sum insured. The balance has to be borne by
you if the under-insured amount is more than 10% of the market value.

Page 4 28-12-2023 11:43:01 AM

 PRIVACY NOTICE c. to manage and maintain your insurance policies with us;
d. to better manage our business and your relationship with us;
At Liberty General Insurance Berhad, we value your privacy and strive to protect e. to better understand your current insurance coverage and future
your personal information in compliance with the laws of Malaysia. insurance needs;
f. to provide you with information on our and third party products, services and
We will only collect and use your personal information in accordance with such offers which may be of interest to you;
laws and regulations (including the Personal Data Protection Act 2010 and g. to improve our products and services and to develop new products and
Insurance Code of Practice), this Privacy Notice and the privacy terms in any services;
agreement(s) that you have entered into and/or will enter into with Liberty h. to notify you about benefits and changes to the features of our products and
General Insurance Berhad. services;
i. to administer offers, competitions and promotions;
This Privacy Notice explains: j. to respond to your enquiries and complaints and to generally resolve
disputes;
• The type of personal information we collect and how we collect it k. to update, consolidate and improve the accuracy of our records;
• How we use your personal information l. to produce data, reports and statistics which have been anonymised or
• The parties that we disclose the personal information to aggregated in a manner that may not identify you specifically as an
• The choices we offer, including how to access and update your individual;
personal information m. to conduct research for analytical purposes including but not limited to data
mining and analysis of your transactions / your use of our products and
For the avoidance of doubt, this Privacy Notice is applicable only if you are an services;
individual. n. to meet the disclosure requirements of any law binding on Liberty General
Insurance Berhad;
o. for audit, compliance and risk management purposes;
For the purposes of this Privacy Notice, please note that:
p. to assess financial and insurance risks;
q. to transfer or assign our rights, interests and obligations under any of your
• “Personal information” refers to any information which relates directly or agreements with us;
indirectly to you and/or your transactions with us. This information
r. to protect or enforce our rights to recover any debt owing to us;
includes your name, address, occupation, contact details, the details of
s. to conduct anti-money laundering and anti-terrorist financing checks;
your account(s), the type of products and/or services subscribed to and
t. for crime detection, prevention and prosecution; and/or
such other necessary information regarding yourself and your
u. for any other purpose(s) that is required or permitted by any law,
transaction(s) with us, and includes sensitive personal information.
regulations, guidelines and/or relevant regulatory authorities.
• “Sensitive personal information”, refers to information relating to your
health, political opinions, religious beliefs, etc.
We will ask for your consent before using your personal information for a purpose
• “Other insured parties” refers to your jointly insureds and/or other other than those that are set out in this Privacy Notice and/or in the privacy terms
individuals you may be purchasing our products and/or services for, e.g.
of any of your agreement(s) with us.
your children or employees, from whom you have (where applicable)
obtained consent in order to disclose their Personal Information to Liberty
DISCLOSURE OF YOUR PERSONAL INFORMATION
General Insurance Berhad.
• “we”, “us” and “our” refers to Liberty General Insurance Berhad. As part of providing you with our products and services and the management
• “you” and “your” refers to you and, where applicable, to your other insured and/or operation of the same, we may be required or need to disclose information
parties. about you and/or your insurance policies with us to the following third parties:
WHAT KIND OF PERSONAL INFORMATION WE COLLECT AND HOW WE a. companies and/or organisations that act as our agents, service providers
COLLECT IT (including but not limited to cloud service providers) and/or professional
advisers;
In order to enable us to deal with your inquiries, open and operate an insurance b. companies and/or organisations that assist us in processing, administering
policy for you and/or to generally provide you with our insurance products and and/or otherwise fulfilling transactions that you have requested;
services ("products and services"), we may need to and/or may be required to c. companies and/or organisations that assist us in providing value added
collect, use, disclose and store (i.e. "process") personal information and services;
financial information about you, including but not limited to: d. advisers (including but not limited to agents, accountants, auditors, lawyers,
financial advisers, brokers, intermediaries or other professional advisers);
a. personal information to establish your identity and background; e. any person notified by you as authorised to give instructions to us on your
b. personal information to establish your financial standing and behalf;
creditworthiness, where required; f. any third party as a result of any restructuring of the insurance policies
c. personal information to establish a view with regard to your health where granted to you or the sale of debts, or the acquisition or sale of any company
you wish to procure relevant insurance policies offered by us; and/or by Liberty General Insurance Berhad, provided that any recipient uses your
d. personal information that you provide when you apply for any of our information for the same purposes as it was originally supplied to us and/or
products and services. used by us;
g. any rating agency, co-insurer or insurance broker or re-insurer or provider
We may obtain this information from you and from a variety of sources, of credit protection;
including but not limited to: h. any person connected to the enforcement or preservation of any of our rights
under your agreement(s) with us; and/or
a. through your relationship with us, for example information provided by you i. competent foreign authorities and/or regulators,
in application forms, when using our products or services, when using our
online or electronic services, when taking part in customer surveys, subject at all time to any laws, (including regulations, guidelines and/or
competitions and promotions; obligations) applicable to the Liberty General Insurance Berhad (whether in or
b. through your verbal, written and/or electronic communications with us outside Malaysia).
and/or our authorised agents;
c. from third parties connected with you, such as your employers and/or We will otherwise treat your personal information as private and
your other insured parties; confidential and will not disclose your information to anyone outside the
d. from an analysis of your access and use of our products and services, the Liberty General Insurance Berhad except:
claims you make, and the payments effected through or for your
insurance policy(ies); a. where you have given permission;
e. from such other sources in respect of which you have given your consent b. where you have not chosen to opt-out of receiving marketing materials from
to disclose information relating to you and/or where not otherwise us or any of our third party business partners;
restricted. c. where we are required or permitted to do so by law;
d. where required or authorised by any order of court, tribunal or authority,
In instances where you provide us with personal information relating to third whether governmental or quasi-governmental with jurisdiction over Liberty
parties, you confirm that you have obtained their prior consent to provide us with General Insurance Berhad;
their personal information in accordance with this Privacy Notice or are e. where we may transfer rights and obligations under our agreement(s) with
otherwise entitled to provide this information to us and for us to use it you; and/or
accordingly. f. where we are required to meet our obligations to any relevant regulatory
authority.
HOW WE USE YOUR PERSONAL INFORMATION

Other than as stated above, we may use your personal information for one
or more of the following purposes:

a. to assess and to manage your application(s) for our products and

services;
b. to verify your financial standing through credit reference/reporting
checks;
 You can also assist us to keep your personal information (such as your current
EXERCISING YOUR CHOICE IN RESPECT OF THE DISCLOSURE AND
mailing address) up to date, as it will enable us to serve you better.
USE OF YOUR PERSONAL INFORMATION FOR PURPOSES OF
MARKETING
Opting Out of Receiving Direct Marketing
We may use your personal information to provide you with information about
our and third party services and/or products, which may be of interest to or We at Liberty General Insurance Berhad are committed to ensuring that our
benefit you, except where otherwise requested by you.
customer’s request to not receive marketing material(s) through email, text
message or telephone call are adhered to.
In certain instances, we may disclose your personal information to our preferred
merchants and strategic partners. However, please note that we will only Please complete the Direct Marketing Opt-Out Form which is made available at
disclose your personal information to our merchants and strategic partners our Head Office, branches or corporate websites, and list your phone number(s)
where your prior consent has been obtained and subject at all times to any and email address(es) that you wish to opt-out of.
laws (including regulations, guidelines and/or obligations) applicable to us.
The completed form can be submitted via email to
We take reasonable steps to ensure that our agreements with our merchants
customer@libertyinsurance.com.my or customer@amassurance.com.my or
and/or strategic partners include appropriate privacy and confidentiality
customer@kurnia.com or directly to any Liberty General Insurance Berhad
obligations.
branch office.
If you do not wish your personal information to be utilised for the purposes of Should you change your mind and wish to receive marketing material(s) again,
marketing or should you change your mind in relation to your previous decision, please send your written request to customer@libertyinsurance.com.my or
please contact us at the address detailed at the end of this Privacy Notice. Your customer@amassurance.com.my or customer@kurnia.com and a Customer
latest written instructions to us will prevail. Care Officer will contact you to confirm your request. All requests will be
processed in 5 working days.
STORAGE AND SECURITY OF YOUR PERSONAL INFORMATION
Revisions To Privacy Notice
Your personal information will be kept confidential and may be held or stored
locally, regionally or globally, or on a cloud based tracking system, whether in This Privacy Notice may be revised from time to time. Notice of any such
Malaysia or out of Malaysia and be it managed internally or operated externally by revision will be given on Liberty Insurance Berhad´s websites and/or by such
third party service providers. Regardless of where your personal information is other means of communication deemed suitable by Liberty General Insurance
processed, we apply the same protection described in this Privacy Notice and we Berhad.
comply with applicable laws when transferring your personal information outside of
Malaysia.
Enquiries / Complaints / Communication
Liberty General Insurance Berhad places great importance on ensuring the
Should you have any queries, concerns, or complaints in relation to this Privacy
security of your personal information. We regularly review and implement up-
Notice or would like to have a copy of the above-mentioned form(s), kindly
to-date technical and organisational security measures when processing your
personal information. contact us during office hours (Monday to Thursday – 8.30 am to 5.30 pm,
Friday – 8.30 am to 4.15 pm, excluding public holidays) at the following contact
points:
Branches and employees of Liberty General Insurance Berhad are trained to
handle the personal information securely and with strict confidentiality, failing
Designation: Customer Service Executive, Customer Contact Centre
which they may be subject to disciplinary action.
Telephone: 1 300 88 8990
E-mail: customer@libertyinsurance.com.my
RETENTION OF YOUR PERSONAL INFORMATION
Address: Corporate Tower 9, Level 13A, Pavilion Damansara
Heights, 3 Jalan Damanlela, 50490 Kuala Lumpur
Liberty General Insurance Berhad will retain your personal information in
compliance with this Privacy Notice and/or the terms and conditions of
your agreement(s) with Liberty General Insurance Berhad: Designation: Customer Service Executive, Customer Contact Centre
Telephone: 1 800 88 6333
a. for the duration of your relationship with us; E-mail: customer@amassurance.com.my
b. for such period as may be necessary to protect the interests of Liberty Address: Corporate Tower 9, Level 13A, Pavilion Damansara
General Insurance Berhad and/or its customers as may be deemed Heights, 3 Jalan Damanlela, 50490 Kuala Lumpur
necessary;
c. where otherwise required by the law; and/or Designation: Customer Service Executive, Customer Contact Centre
d. where required by Liberty General Insurance Berhad's relevant policies. Telephone: 1 800 88 3833
E-mail: customer@kurnia.com
What If Personal Information Provided By You Is Incomplete? Address: Corporate Tower 9, Level 13A, Pavilion Damansara
Heights, 3 Jalan Damanlela, 50490 Kuala Lumpur
Where indicated (for example in insurance application forms), it is obligatory to
provide your personal information to us to enable us to process your application A current version of this Privacy Notice and the abovementioned forms are made
for our products or services. Should you decline to provide such obligatory available on our website at: www.libertyinsurance.com.my or
personal information, we may not be able to process your application/request www.amgeneralinsurance.com or www.amassurance.com.my or
or provide you with our products or services. www.kurnia.com

Your Rights To Access And Correct Your Personal Information

We can assist you to access and correct your personal information provided to
us.

Where you wish to have access to your personal information in Liberty General
Insurance Berhad´s possession, or where you are of the opinion that such
personal information held by us is inaccurate, incomplete, misleading or where
relevant, not up-to-date, you may make a request to us by contacting our
branches or any relationship manager you usually deal with or alternatively you
may make such request via our Data Access Request Form or Data Correction
Request Form respectively. These forms are available at our Head Office,
branches or corporate websites.

We will use reasonable efforts to comply with your request to access or correct
your personal information within 21 days of receiving your duly completed Data
Access Request Form/Data Correction Request Form and the relevant
processing fee (if any).

Please note that Liberty General Insurance Berhad may have to withhold
access to your personal information in certain situations, for example when we
are unable to confirm your identity or where information requested for is of a
confidential commercial nature or in the event we receive repeated requests
for the same information. Nevertheless, we will notify you of the reasons for not
being able to accede to your request.

Please also note that Liberty General Insurance Berhad may use its discretion
in allowing the corrections requested and/or may require further documentary
evidence of the new information to avoid fraud and inaccuracy.
 LETTER OF UNDERTAKING
To / Kepada : Liberty General Insurance Berhad
Corporate Tower 9
Level 13A
Pavilion Damansara Heights
3 Jalan Damanlela
50490 Kuala Lumpur
Tel 1 800 88 3833 Email customer@kurnia.com Website www.kurnia.com
From / Daripada : NUR HAFIZAH BINTI FHAUDZI
NO 105 LALUAN 4
TAMAN MANJUNG BARU
32040 SERI MANJONG

Date / Tarikh : 29-01-2023

Dear Sir / Tuan / Puan,

NCD Entitlement / Kelayakan Diskaun Tanpa Tututan : 0.00%
Vehicle No / Nombor Kenderaan : PFD1969
I/C No. (Old/New) / Nombor Kad Pengenalan (Lama/Baru) : 910802115022

I am currently holding a valid *COMPREHENSIVE PLUS motor policy with __________________________________________________________

(Current Insurer).

I intend to transfer or claim my 0.00% NCD entitlement to a Vehicle No. PFD1969 to be insured with You or purchase a policy from Your Company.

I hereby confirm that:-

(a) to the best of my knowledge I have not been involved in an accident in which a claim or Court Action has been lodged / pending or is
likely to be taken against me under the policy.

(b) there is no breach of any policy condition(s) which affects my NCD entitlement.

(c) I have not and shall not use this entitlement of NCD for any other vehicle / policy.

(d) if the NCD is incorrect, I undertake to pay the difference of premium within 14 working days, failing which I agree the policy shall be
cancelled by the company.
Ketika ini saya merupakan pemegang sah * Komprehensif Plus polisi motor dengan _______________________________________ (Penanggung
insurans sekarang).

Saya ingin memindahkan atau menuntut 0.00% kelayakan Diskaun Tanpa Tuntutan saya ke kenderaan bernombor
PFD1969 untuk diinsuranskan dengan Anda atau membeli polisi daripada syarikat Anda.

Saya dengan ini mengesahkan bahawa:-

(a) dalam pengetahuan saya, saya tidak pernah terlibat dalam sebarang kemalangan di mana ada tuntutan atau Tindakan Mahkamah telah
dibuat/belum selesai atau kemungkinan akan diambil terhadap saya di bawah polisi ini.

(b) tiada perlanggaran pada mana-mana syarat polisi yang boleh menjejaskan kelayakan Diskaun Tanpa Tuntutan saya.

(c) Saya belum dan tidak akan menggunakan kelayakan Diskaun Tanpa Tuntutan ini untuk mana-mana kenderaan/polisi yang lain.

(d) sekiranya Diskaun Tanpa Tuntutan ini tidak betul, Saya memberi akujanji untuk membayar balik perbezaan premium dalam masa 14
hari bekerja, sekiranya gagal berbuat demikian, Saya bersetuju polisi saya dibatalkan oleh Syarikat.

(Insured Signature / Tandatangan pihak yang diinsuranskan)

Note / Nota:

NCD from Overseas / Diskaun Tanpa Tuntutan daripada Luar Negara

Duly Signed Letter of Undertaking and the original NCD confirmation letter stating the number of claims free years must be submitted.
Surat Akujanji yang ditandatangani sewajarnya dan surat pengesahan asal Diskaun Tanpa Tuntutan yang menyatakan bilangan tahun
bebas tuntutan mestilah disertakan.

* delete whichever is not applicable.

* potong yang mana tidak berkenaan.

Page 1
 RANCAK JAYA AGENCY Agency Code : T58300-00

Liberty General Insurance Berhad NO 47 JALAN SEROM BARU 1, TAMAN SEROM BARU,
197801007153 (44191-P) SUNGAI MATI,
Formerly known as AmGeneral 84400 TANGKAK
Insurance Berhad JOHOR

MOTOR INSURANCE PROPOSAL FORM / BORANG CADANGAN INSURANS MOTOR

Date/time issued (dd/mm/yyyy) / Tarikh/masa dikeluarkan (hh/bb/tttt) 29-01-2023 10:25:09 AM

IMPORTANT NOTICE / NOTIS PENTING

1. STATEMENT PURSUANT TO FINANCIAL SERVICE ACT 2013,
SECTION 129, SCHEDULE 9, PARA 5: It is the duty of the customer to
take reasonable care not to make a misrepresentation to the licensed
insurer when answering any question which the insurer may request that
are relevant to the decision of the insurer whether to accept the risk or not
and the rates and terms to be applied. 2. YOUR ATTENTION IS DRAWN
TO SECTION 84 OF THE FINANCIAL SERVICES ACT 2013: It has been
prescribed by law that insurance cover shall only be issued by insurers or
their agents on a 'cash before cover' basis, therefore premiums must be
paid before the Company issues you with a motor insurance cover note or
policy. Payment must be made by cash or credit card. Please insist on a
receipt for the premium paid as proof of payment for future reference. 3.
Passenger Liability Cover -If you intend to drive your vehicle into the
Republic of Singapore, you are required by Singapore’s law to have cover
for ‘Legal liability to passengers (LLP)’ and you can purchase this cover
under ‘optional cover’ which provides a limited cover for your liability for
death and bodily injury of passenger(s). 4. Product Disclosure Sheet
(PDS) can be obtained through our website. You are advised to read the
PDS before you take out insurance policy. 5. Privacy Notice:A full version
of the Privacy Notice of Liberty General Insurance Berhad is available on
our website at www.libertyinsurance.com.my for your further reference.
1. MENURUT AKTA PERKHIDMATAN KEWANGAN 2013, SEKSYEN
129, JADUAL 9, PERENGGAN 5: Adalah menjadi kewajipan pengguna
untuk mengambil penjagaan munasabah untuk tidak membuat salah
nyataan kepada penanggung insurans berlesen semasa menjawab apa-apa
soalan yang diperlukan yang berkaitan dengan keputusan penanggung
insurans sama ada untuk menerima atau tidak risiko dan kadar dan terma
yang hendak dipakai. 2. PERHATIAN ANDA ADALAH DIARAH KEPADA
SEKSYEN 84 AKTAPERKHIDMATAN KEWANGAN 2013: Sebagaimana
ditentukan oleh undang-undang perlindungan insurans akan hanya
dikeluarkan oleh syarikat insurans atau ejen berdasarkan pada bayaran
tunai sebelum perlindungan insurans diberi, oleh yang demikian, premium
mestilah dibayar sebelum pihak Syarikat mengeluarkan nota perlindungan
atau polisi insurans motor. Bayaran hendaklah dibuat secara tunai atau kad
kredit. Sila dapatkan resit sebagai bukti pembayaran telah dibuat untuk
rujukan dimasa hadapan.3. Perlindungan Liabiliti Penumpang- Jika anda
bercadang untuk memandu kenderaan anda ke Republik Singapura, anda
dikehendaki di bawah undang-undang Singapura untuk mempunyai
‘Perlindungan liabiliti penumpang (PLP)’ dan anda boleh membeli
perlindungan ini di bawah ‘perlindungan opsyenal’ yang menyediakan
perlindungan terhad bagi liabiliti anda terhadap kematian dan kecederaan
tubuh badan penumpang.4. Lampiran Pemberitahuan Produk (PDS)boleh
didapati di laman web kami. Anda adalah dinasihati untuk membaca PDS
sebelum anda memutuskan untuk mengambil polisi insurans.5. Notis
Privasi:Versi lengkap Notis Privasi Liberty General Insurance Berhad boleh
didapati di laman web kami di www.libertyinsurance.com.my untuk rujukan
lanjut.

DETAILS OF PROPOSER / BUTIR-BUTIR PENCADANG

Name of proposer / Nama pencadang NUR HAFIZAH BINTI FHAUDZI

Correspondence address / Alamat surat-menyurat NO 105 LALUAN 4

TAMAN MANJUNG BARU

32040 Nationality / Warganegara Malaysia

NRIC No./Passport No./Business registration No. / No. Kad Date of birth/

pengenalan baru/No. Pasport/No. pendaftaran syarikat 910802115022 / - Tarikh lahir 02-08-1991

Occupation/Trade / Pekerjaan/Perdagangan NURSE

Nature of business / Jenis perniagaan PROFESSIONAL SERVICES

Tel. no (hse) / No. tel (rumah) Tel. no (off) / No. tel (pejabat)

Handphone no. / No. tel bimbit 0179016684 Email / E-mel KIRAJADI2USERVICES@GMAIL.COM

Marital status / Status perkahwinan Married Gender/Corporate / Jantina/Korporat Female

Head Office Postal Address Customer Contact Website

Corporate Tower 9,Level P. O. Box 6120 Pudu, 1 800 88 3833 www.kurnia.com
13A,Pavilion Damansara 55916 Kuala Lumpur,
Heights,3 Jalan Damanlela,50490 Malaysia.
Kuala Lumpur. Page 2
 RANCAK JAYA AGENCY Agency Code : T58300-00
Liberty General Insurance Berhad
NO 47 JALAN SEROM BARU 1, TAMAN SEROM BARU,
197801007153 (44191-P)
SUNGAI MATI,
Formerly known as AmGeneral 84400 TANGKAK
Insurance Berhad JOHOR

DETAILS OF VEHICLE / BUTIR-BUTIR KENDERAAN

Make and type of vehicle / Buatan dan jenis kenderaan PERODUA KELISA EZ & 4D HATCHBACK

Use of vehicle / Penggunaan kenderaan NOT APPLICABLE TO ABOVE USAGE

Additional usage / Penggunaan tambahan Not Applicable

Reg. no. / Trailer no. / No. pendaftaran/No. PFD1969 / - Year of manufacturing / Tahun 2002
Vehicle for business use / Kenderaan untuk penggunaan perniagaan Yes / Ya X No / Tidak

Engine no. / No. enjin B016609 Chassis no. / No. chassis PM2L701S002016627

Seating capacity / Muatan tempat duduk 5 CC / KG / Horse power / CC/KG/Kuasa kuda 989.00 CC

Vehicle sum insured / Jumlah kenderaan diinsuranskan (RM) 10,000.00

Basis of coverage / Jenis perlindungan X Agreed Value / Nilai Dipersetujui Market Value / Nilai Pasaran

Trailer sum insured / Jumlah treler diinsuranskan (RM) 0.00

Vehicle purchase date / Tarikh pembelian kenderaan -

Vehicle purchase price / Harga pembelian kenderaan (RM) 0.00

Optional cover / Perlindungan opsyenal Compensation For Assessed Repair Time (CART), Windscreen Damage (Tempered/Laminated Glass
Inclusive Labour Cost)(RM 800.00)

Named driver / rider / Pemandu yang dinamakan/penunggang ANY AUTHORISED DRIVER

Hire purchase owner / Pemilik sewa beli -

Is your vehicle normally kept at your corresponding / mailing address? / Adakah kenderaan anda biasanya disimpan di alamat kediaman

/ surat-menyurat anda?
X Yes / Ya No, Please specify vehicle kept address / Tidak, sila nyatakan alamat penyimpanan kenderaan anda

Garaged / Garaj PARKING LOT - COVERED Safety code / Kod keselamatan NONE

No. of claims (for the past 3 years) / Daily driving hours /

No. tuntutan (untuk 3 tahun lepas) Jam memandu harian

DETAILS OF NO CLAIM DISCOUNT (NCD) / BUTIR-BUTIR DISKAUN TANPA TUNTUTAN (NCD)

Name of previous insurer / Nama syarikat insurans terdahulu

Reg. no. / No. pendaftaran PFD1969 Policy no. / No. polisi -

NCD % / RM 0.00 / 0.0 as at / pada 1/30/23 12:00 AM

PREMIUM AND COVERAGE / PREMIUM DAN PERLINDUNGAN

Type of Cover / Jenis Perlindungan: COMPREHENSIVE PLUS

Period of Insurance / Tempoh Insurance / From / Dari 00:00:01 AM 30-01-2023

Total Premium Due (inclusive of Service Tax and Stamp Duty) /

Jumlah Premium Dikehendaki (termasuk Cukai Perkhidmatan dan Duti Setem) 1,055.32

Page 3
 RANCAK JAYA AGENCY Agency Code : T58300-00
Liberty General Insurance Berhad NO 47 JALAN SEROM BARU 1, TAMAN SEROM
197801007153 (44191-P) BARU, SUNGAI MATI,
84400 TANGKAK
Formerly known as AmGeneral JOHOR
Insurance Berhad
DECLARATION OF PROPOSER / PENGAKUAN PENCADANG
I/We hereby confirm that I/We have taken reasonable care to answer all the questions herein honestly and to the best of My/Our
knowledge, belief and recollection and that I/We shall remain under a continuous duty to inform the Company of any change,
amendment or addition to the aforesaid questions until the Policy is issued and comes into effect. I/We understand that the Company
may void the policy and reject any claim payable thereunder (whether in whole or in part) in the event of a deliberate
misrepresentation, misdescription, error, omission or non-disclosure of fact (whether or not there was an inquiry/question raised
pertaining to the same) with or without an intention to defraud the Company by Me/Us which would have affected the premium payable
or the acceptance of the risk by the Company. / Saya/Kami mengesahkan bahawa Saya/Kami telah memberi sepenuh perhatian untuk
menjawab kesemua soalan yang terkandung secara jujur di sepanjang pengetahuan, kepercayaan dan ingatan. Saya/Kami akan
bertanggungjawab untuk memberitahu pihak Syarikat sebarang perubahan, pindaan atau penambahan pada soalan di atas sehingga
Polisi dikeluarkan dan berkuatkuasa. Saya/Kami faham bahawa Syarikat boleh membatalkan Polisi ini dan menolak sebarang tuntutan
(sama ada keseluruhan atau sebahagian) sekiranya berlaku salah nyata, penerangan yang salah, kesilapan, tertinggal atau tidak
mendedahkan fakta (sama ada terdapat pertanyaan/persoalan ataupun tidak dikemukakan mengenai yang sama) dengan niat atau
tanpa niat untuk menipu Syarikat oleh Saya/Kami yang akan menjejaskan premium yang perlu dibayar atau terhadap penerimaan
risiko oleh pihak Syarikat.

Yes / Ya No / Tidak
I/We agree that the Company shall have the right to use My/Our data and personal information for the purpose of the insurance
operational process which might include transfer of data and personal information to the Company’s related companies, subsidiaries
and/or its holding company, outsourcing partners, reinsurers and solicitor but not limited to affiliate companies including their
outsourcing partners. / Saya/Kami bersetuju bahawa pihak Syarikat berhak untuk menggunakan data dan maklumat peribadi
Saya/Kami bagi tujuan pemprosesan operasi insurans yang mungkin termasuk pemindahan data dan maklumat peribadi kepada
Syarikat yang sekutu dengan pihak Syarikat, anak-anak syarikat dan/atau syarikat induknya, semua rakan kongsi pembekalan luar,
penanggung insurans semula dan peguam cara tetapi tidak terhad kepada syarikat-syarikat sekutu termasuk rakan kongsi pembekalan
luar mereka.

Yes / Ya No / Tidak
I/We further agree that the Company, its partners and its related companies, subsidiaries and/or its holding company can share and
use My/Our data and personal information for the purpose of promoting the Company’s and its related companies’, subsidiaries’ and/or
its holding company’s products, new services and support requirements; and marketing campaigns and activities and commercial
transactions. / Saya/Kami seterusnya bersetuju bahawa pihak Syarikat, rakan niaganya dan syarikat-syarikat sekutu, anak-anak
syarikat dan/atau syarikat induk berhak untuk berkongsi dan menggunakan data dan maklumat peribadi untuk tujuan mempromosikan
produk, perkhidmatan baru dan keperluan sokongan; dan kempen dan aktiviti pemasaran dan transaksi komersil yang dikendalikan
oleh pihak Syarikat dan syarikat sekutu, anak-anak syarikat dan/atau syarikat induk.

Yes / Ya No / Tidak
Signature of proposer /
Company’s chop /
Date /
Tandatangan pencadang /
Tarikh
Chop syarikat

ANTI-MONEY LAUNDERING, ANTI-TERRORISM FINANCING AND PROCEEDS OF UNLAWFUL ACTIVITIES ACT 2001 /
AKTA PENCEGAHAN PENGUBAHAN WANG HARAM, PENCEGAHAN PEMBIAYAAN KEGANASAN DAN HASIL DARIPADA AKTIVITI
HARAM 2001

For Agent / Staff Use Only / Untuk Ejen / Kakitangan Sahaja

In Compliance with Section 16(2) of the Anti-Money Laundering, Anti-Terrorism Financing and Proceeds of Unlawful Activities
Act 2001, I hereby certify that the Proposer’s original NRIC / Business Registration Certificate / Passport was verified and
authenticated by me at the Point of Sale. / Menurut Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram, Pencegahan
Pembiayaan Keganasan dan Hasil daripada Aktiviti Haram 2001, saya dengan ini mengesahkan bahawa Kad Pengenalan (KP)
/ Sijil Pendaftaran / Pasport asal Pencadang telah disahkan ketulenannya ketika urusniaga dijalankan.

Name of Proposer / Nama Pencadang

Cover Note / Policy No. / No. Sijil Insurans / Polisi

VERIFICATION / PENGESAHAN
Name of agent / staff / Nama ejen / kakitangan

NRIC no. / No. KP Date / Tarikh Signature / Tandatangan

Page 4