Brosur ini untuk maklumat am sahaja. Ia bukannya kontrak Insurans. Anda dinasihati supaya membaca dan memahami ringkasan produk ini seperti yang tertera di dalam Lampiran Pemberitahuan Produk yang boleh didapati di laman web kami www.amassurance.com.my

Kelayakan bagi Pihak Diinsuranskan/Pemegang Polisi:Pemilik Kereta Persendirian berumur 17 tahun dan ke atas.

Faedah Pemegang Polisi (Pihak

Diinsuranskan)

Pemandu Yang Dibenarkan/Penumpang

Jumlah Yang Diinsuranskan (RM)

Kenderaan Persendirian

Seorang pemandu dan sehingga 4 penumpang (termasuk 6% GST dan duti setem RM10)

Setiap penumpang tambahan (termasuk 6% GST)

84.20

Premium Tahunan (RM)

8.48

NOTIS PENTINGPembayaran premium - Tunai sebelum perlindungan Anda mesti membayar premium sebelum perlindungan di bawah Polisi ini berkuatkuasa.

Kematian akibat kemalangan (setiap orang)

Hilang upaya kekal seperti yang dinyatakan dibawah (setiap orang):

Lumpuh menyeluruh

Terlantar kekal dikatil

Kehilangan kedua-dua tangan dan/atau kedua-dua kaki

Kehilangan penglihatan kedua-dua mata

Kehilangan pendengaran kedua-dua telinga

Kehilangan satu tangan atau kaki dan penglihatan sebelah mata

Kehilangan satu tangan atau kaki

Kehilangan penglihatan sebelah mata atau pendengaran sebelah telinga

Perbelanjaan perubatan (setiap orang)

Pembedahan pembetulan gigi dan/atau pembedahan kosmetik (setiap orang)

Yuran ambulan (setiap orang)

Pendapatan hospital (setiap orang, sehingga maksimum 60 hari setiap tahun)

Perbelanjaan Ehsan Akibat BanjirPerbelanjaan sebenar yang ditanggung disebabkan oleh kerosakan akibat banjir kepada kenderaan yang dinamakan (maksimum setiap kejadian/setiap tempoh insurans)

Indemniti berganda ketika Cuti Umum Seluruh Malaysia (setiap orang)

Perkhidmatan bantuan kerosakan kenderaan dan perkhidmatan tunda di Malaysia (setiap kejadian) termasuk caj tol tanpa had

Sehingga 450km pergi balik bagi kenderaan yang dinamakan

dalam jadual polisi

20 sehari 20 sehari

1,000 setiap kemalangan

1,000 setiap kemalangan

1,000 Tidak Berkenaan

15,000 7,500

60,000 30,000

30,000 15,000

30,000 15,000

Declaration / Perakuan

I hereby confirm the above inform

ation provided in this standing instruction is correct and true. In the event of any changes or cancellation of the instruction above, I shall keep AmGeneral

Insurance Berhad informed in w

riting or by giving a fresh standing instruction. / Saya dengan ini mengesahkan bahaw

a maklum

at yang diberikan untuk arahan perkhidmatan auto debit

ini adalah benar dan tepat. Sekiranya saya ingin mem

buat sebarang perubahan atau pembatalan, saya akan m

emberitahu Am

General Insurance Berhad secara bertulis atau dengan mem

beri arahan perkhidm

atan auto debit yang baru.

Signature of Cardmem

ber / Tandatangan Pemegang Kad

D

ate / Tarikh(Signature m

ust correspond with specim

en signature of the Credit Cardmem

ber at the bank) / (Tandatangan semestinya sam

a dengan tandatangan spesimen Pem

egang Kad Kredit di bank)

For Agent / Staff U

se Only / U

ntuk Ejen / Kakitangan SahajaA

nti-Money Laundering, A

nti-Terrorism Financing and Proceeds of U

nlawful A

ctivities Act 2001/

Akta Pencegahan Pengubahan W

ang Haram

, Pencegahan Pembiayaan Keganasan dan H

asil daripada Aktiviti H

aram 2001

In Compliance w

ith Section 16(2) of Anti-Money Laundering, Anti-Terrorism

Financing and Proceeds of Unlawful Activities Act 2001, I hereby certify that the Proposer’s original N

RIC/Business Registration Certificate/Passport w

as verified and authenticated by me at the Point of Sale. / M

enurut Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram

, Pencegahan Pem

biayaan Keganasan dan Hasil daripada Aktiviti Haram 2001, saya dengan ini m

engesahkan bahawa Kad Pengenalan (KP)/ Sijil Pendaftaran Perniagaan/Pasport asal Pencadang telah

disahkan ketulenannya ketika urus niaga dijalankan. Signature / Tandatangan :

Nam

e of Agent / Staff / Nama Ejen / Pekerja

NRIC N

o. / No. KPD

ate / Tarikh

Nom

ination Form / Borang Penam

aan

Nam

e / Nama

Address / Alamat

Birth Cert. / NRIC N

o. / Sijil Kelahiran / No. KP

Date of Birth / Tarikh Lahir

Relationship / Hubungan

Share / Bahagian (%

)

If your intention is for the nominee(s) nam

ed herein to receive the policy benefits beneficially and not as an executor, then you must assign the benefits of the policy to such person(s)

using the Absolute Assignment Form

. (Note: 1. The w

itness must be at least 18 years of age and cannot be a nam

ed nominee. 2. A nom

inee of a Muslim

policy owner upon receipt

of policy money shall distribute the policy m

oney in accordance with Islam

ic Law. 3. PURSUAN

T TO FIN

ANCIAL SERVICES ACT 2013, Section 130, Schedule 10, Para 5; For N

on-M

uslim, a trust is autom

atically created if the nominee is a i) spouse ii) child or iii) parent w

ho is being nominated w

hen there is no spouse or child living at the time of m

aking the nom

ination. No assignm

ent is therefore required). / Jika anda mahu supaya penam

a yang dinyatakan dalam pelan ini m

enerima m

anfaat polisi sebagai pewaris dan bukannya sebagai

wasi, m

aka anda mestilah m

enyerahkan hak manfaat polisi berkenaan kapada orang tersebut m

enggunakan Borang Serah Hak mutlak (Nota: 1. Saksi m

estilah berumur sekurang-

kurangnya 18 tahun dan tidak boleh dinyatakan sebagai penama. 2. Seseorang penam

a bagi pemilik polisi yang beragam

a Islam, apabila m

enerima w

ang polisi menurut undang-undang

Islam. 3. M

ENURUT AKTA PERKHIDMATAN KEW

ANGAN 2013, Seksyen 130, Jadual 10, Perenggan 5; Bagi yang bukan beragama Islam

, amanah dangan sendirinya diw

ujudkan jika penama

i) suami/isteri ii) anak atau iii) ibu bapa yang dilantik sebagai penam

a apabila tiada suami-isteri atau anak yang m

asih hidup semasa penam

aan itu dibuat).

Signature of Witness / Tandatangan Saksi

Signature of Proposer / Tandatangan Pencadang N

ame / N

ama

: N

ame / N

ama

: N

RIC No. / No. KP

: N

RIC No. / No. KP

:Address / Alam

at :

Address / Alamat

:D

ate / Tarikh :

Date / Tarikh

:

Payment Instruction / Arahan Pem

bayaranc

By Cash/Cheque / Secara Tunai/Cek

I enclose cash/cheque no.

for RM

m

ade payable to AmGeneral Insurance Berhad. /

Saya lampirkan w

ang tunai/cek no. berjum

lah RM

dibayar kepada AmGeneral Insurance Berhad.

c By Credit Card Paym

ent / Pembayaran secara

Kad Kredit :

Direct D

ebit Authorisation / Kebenaran D

ebit LangsungI hereby request and authorise Am

General Insurance Berhad to debit my credit card account indicated below

for the amount of RM

being

the annual premium

including the subsequent years renewal due or such other am

ount (in RM) as advised by Am

General Insurance Berhad until the policy is cancelled or expired as per term

s and conditions stated in the policy.Saya dengan ini m

emohon dan m

emberi kuasa kepada Am

General Insurance Berhad untuk mendebit akaun kredit saya yang butirannya tertera di baw

ah sebanyak RM

bagi pem

bayaran premium

tahunan termasuk untuk pem

baharuan premium

bagi tahun-tahun berikutnya atau jumlah (RM

) lain seperti yang dimaklum

kan oleh AmGeneral Insurance Berhad sehingga

polisi dibatalkan atau tamat tem

poh mengikut term

a-terma dan syarat-syarat yang dinam

akan di dalam polisi.

It is important to retain your receipt as proof of paym

ent. / Sila simpan resit sebagai bukti pem

bayaran.

c M

asterCard c

VISA

Nam

e of Cardmem

ber Nam

a Pemilik Kad

Cardmem

ber’s Account No.

No. Akaun Pemilik Kad

Nam

e of Insured Nam

a Pihak Yang DiinsuranskanCredit Card Expiry D

ate Tarikh Tam

at Tempoh Kad Kredit

1117

1300 80 3030 | amassurance.com.myUnderwritten by / Ditanggung jamin oleh :

AmGeneral Insurance Berhad (44191-P)

A member of the AmBank Group

Our protection extends to all on board24 hours coverage with reliable auto assistance service.

AmDrive Plus

AmAssurance-AmDrive Plus Brochure revise (Sum Insured)-FA.indd 1 30/10/2017 4:03 PM

Faedah 24 Jam Perkhidmatan Bantuan Kerosakan Kenderaan dan Perkhidmatan Tunda di seluruh Malaysia, termasuk:

• Perkhidmatan bantuan kerosakan kenderaan dan perkhidmatan tunda sehingga 450km pergi balik dan tidak dihadkan untuk bilangan kejadian

• Caj Tol tanpa had

• Menukar tayar pancit

• Mengganti Bateri (jika bateri baharu diperlukan, perbelanjaan akan ditanggung oleh Pihak Diinsuranskan/pemandu)

• “Jump Start” enjin Kereta Dinamakan

Sila hubungi 24 Jam AmAssurance 1300-80-3030 untuk perkhidmatan bantuan kerosakan kenderaan dan perkhidmatan tunda (Dikendalikan oleh Kurnia Auto Assist)

Kemalangan kenderaan boleh berlaku pada bila-bila masa, di mana jua dan kepada sesiapa sahaja. Dengan Pelan A m D r i ve P l u s k a m i , a n d a t i d a k perlu bimbang lagi ketika memandu kerana ianya memberikan perlindungan kemalangan yang terbaik.

• Perlindungan komprehensif kurang daripada RM0.25 sehari

• Perkhidmatan bantuan kerosakan kenderaan dan perkhidmatan tunda 24 jam di seluruh Malaysia termasuk caj tol tanpa had

• Kanak-Kanak menikmati had faedah sama seperti had faedah orang dewasa untuk faedah tertentu

• Indemniti berganda ketika Cuti Umum Seluruh Malaysia

• Perbelanjaan Ehsan Akibat Banjir

• 24 jam Perlindungan bagi faedah Kematian Akibat Kemalangan, Hilang Upaya Kekal dan Perbelanjaan Perubatan untuk Pemegang Polisi

Ciri-Ciri Unik

This brochure is not a contract of insurance. The precise terms, exclusions, conditions and definitions applicable to this insurance are specified in the Policy. You are advised to read and understand the summary of this product as contained in the Product Disclosure Sheet on our website www.amassurance.com.my

IMPORTANT NOTICEPayment of premium - Cash before cover You must pay the premium before coverage under this Policy is effective.

Unique Features

• Comprehensive coverage for less than RM0.25 per day

• 24 hours vehicle breakdown assistance and towing services within Malaysia including unlimited toll charges

• Children enjoy the same limit as adult on applicable benefits

• Double indemnity during a National Public Holiday in Malaysia

• Compassionate Flood Expenses

• 24 hours worldwide cover on Accidental Death, Permanent Disablement and Medical Expenses benefits for Policyholder

Motor accidents can happen anytime, anywhere to anyone. Eliminate your worries by protecting yourself through our AmDrive Plus Plan which offers great coverage against accidents.

Benefits of 24-Hour Vehicle Breakdown Assistance and Towing Service within Malaysia includes:

• Vehicle breakdown assistance and towing service up to 450km roundtrip is for an unlimited number of events

• Unlimited toll charges

• Changing of flat tyres

• Replacing battery (if a new battery is required, this will be at Insured/driver’s expense)

• Jump starting of Named Vehicle’s engine

Please call 24-Hour AmAssurance number 1300-80-3030 for vehicle breakdown assistance and towing service (supported by Kurnia Auto Assist)

Eligibility for Insured/Policyholder: Private vehicle owners aged 17 years and above.

Accidental death (per person)

Permanent disablement as specified below (per person):

Total paralysis

Permanently bedridden

Loss of both hands and/or both feet

Loss of sight of both eyes

Loss of hearing of both ears

Loss of either hand or foot and sight of one eye

Loss of either hand or foot

Loss of sight of one eye or hearing of one ear

Medical expenses (per person)

Corrective dental and/or cosmetic surgery (per person)

Ambulance fees (per person)

Hospital income (per person, up to maximum 60 days per year)

Compassionate flood expensesExpenses incurred due to damages caused by flood to the named vehicle (any one incident/any one period of insurance)

Double indemnity during a National Public Holiday in Malaysia (per person)

Vehicle breakdown assistance and towing service within Malaysia (per incident) including unlimited toll charges incurred

Benefits Policyholder (Insured)

Authorised Driver/Passengers

Sum Insured (RM)

Up to 450 km roundtrip to the named vehicle in the policy schedule

20 per day 20 per day

1,000 per accident

1,000 per accident

1,000 Not Applicable

15,000 7,500

60,000 30,000

30,000 15,000

30,000 15,000

Private vehicle

A driver and up to 4 passengers (inclusive of 6% GST and Stamp Duty of RM10)

Each additional passenger (inclusive of 6% GST)

84.20

Annual Premium (RM)

8.48

Am

Driv

e Pl

us P

ropo

sal F

orm

/ Bo

rang

Cad

anga

n Am

Driv

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us

STAT

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RSU

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FIN

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eksy

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adua

l 9, P

eren

ggan

5 :

It is

the

duty

of t

he cu

stom

er to

take

reas

onab

le ca

re n

ot to

mak

e a

misr

epre

sent

atio

n to

the

licen

sed

insu

rer w

hen

answ

erin

g an

y qu

estio

ns w

hich

the

insu

rer m

ay re

ques

t tha

t are

rele

vant

to

the

deci

sion

of th

e in

sure

r whe

ther

to a

ccep

t the

risk

or n

ot a

nd th

e ra

tes a

nd te

rms t

o be

app

lied.

/ Ad

alah

men

jadi

kew

ajip

an p

engg

una

untu

k men

gam

bil p

enja

gaan

mun

asab

ah u

ntuk

tid

ak m

embu

at sa

lah

nyat

aan

kepa

da p

enan

ggun

g in

sura

ns b

erle

sen

sem

asa

men

jaw

ab a

pa-a

pa so

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g di

perlu

kan

yang

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kaita

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ngan

kep

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an p

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ggun

g in

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ns sa

ma

ada

untu

k men

erim

a at

au ti

dak r

isiko

dan

kada

r dan

term

a ya

ng h

enda

k dip

akai

.

Pers

onal

Det

ails

/ Bu

tira

n Pe

riba

di

Nam

e of

Pro

pose

r / N

ama

Penc

adan

g :

Nam

e of

Nom

inat

ed D

river

(For

Com

pany

ow

ned

vehi

cle)

/

Nam

a Pe

man

du ya

ng D

inam

akan

(Unt

uk ke

reta

mili

k Sya

rikat

) :

O

ccup

atio

n / P

eker

jaan

:

N

atur

e of

Bus

ines

s /Je

nis P

erni

agaa

n :

B

usin

ess R

egist

ratio

n N

o. /

No. P

enda

ftara

n Sy

arik

at :

Post

al A

ddre

ss /A

lam

at S

urat

-Men

yura

t :

P

ostc

ode

/ Pos

kod

:

Tel :

(Hom

e / R

umah

)

(Han

dpho

ne /

Tele

fon

Bim

bit)

(O

ffice

/ Pe

jaba

t)

Age

/ Um

ur :

E-m

ail /

E-m

el :

D

ate

of B

irth

/ Tar

ikh

Lahi

r :

Sex

/Jan

tina

:

Mal

e / L

elak

i

F

emal

e / P

erem

puan

N

atio

nalit

y / K

ewar

gane

gara

an :

N

RIC

No.

/ Pa

sspo

rt N

o. /

No. K

P / N

o. P

aspo

rt :

Vehi

cle

Det

ails

/ M

aklu

mat

Ken

dera

an

Vehi

cle

Regi

stra

tion

No.

/ No

. Pen

dafta

ran

Kend

eraa

nSe

atin

g Ca

paci

ty in

clud

ing

Driv

er /

M

uata

n Te

mpa

t Dud

uk te

rmas

uk P

eman

duTy

pe o

f Veh

icle

& M

odel

/ Je

nis K

ende

raan

& M

odel

Gen

eral

Que

stio

nnai

res

/ Soa

lan

Um

um1.

Hav

e yo

u ev

er s

usta

ined

any

inju

ries

by a

ccid

ent d

urin

g th

e la

st 2

yea

rs?

/ Per

nahk

ah a

nda

men

gala

mi a

pa-a

pa ke

cede

raan

aki

bat k

emal

anga

n da

lam

tem

poh

2 ta

hun

yang

lepa

s?

Y

es /

Ya

No

/ Tid

ak

If

Yes

, ple

ase

give

furt

her d

etai

ls /

Jika

Ya, s

ila b

eri p

enje

lasa

n la

njut

:

D

ate

of A

ccid

ent /

Tarik

h Ke

mal

anga

n :

Type

of C

laim

/ Je

nis T

untu

tan

:

A

mou

nt o

f Cla

im /

Jum

lah

Tunt

utan

:

2. H

as y

our i

nsur

ance

pro

posa

l(s) e

ver b

een

decl

ined

, can

celle

d, re

fuse

d re

new

al o

r sub

ject

to a

ny s

peci

al te

rms

by a

noth

er in

sura

nce

com

pany

(ies)

? /

Pern

ahka

h ca

dang

an in

sura

ns a

nda

dito

lak,

dib

atal

kan,

tida

k dip

erba

haru

i ata

u di

kena

kan

seba

rang

syar

at k

has o

leh

syar

ikat

insu

rans

lain

?

Y

es /

Ya

No

/ Tid

ak

If

Yes

, ple

ase

prov

ide

reas

on /

Jika

Ya, s

ila b

erik

an se

bab

:

Dec

lara

tion

/ Pe

raku

an

I/We

here

by c

onfir

m th

at I/

we

have

take

n re

ason

able

car

e to

ans

wer

all

the

ques

tions

her

ein

hone

stly

and

to th

e be

st o

f my/

our k

now

ledg

e, b

elie

f and

reco

llect

ion

and

that

I/w

e sh

all r

emai

n un

der a

con

tinuo

us d

uty

to in

form

the

Com

pany

of a

ny c

hang

e, a

men

dmen

t or a

dditi

on to

the

afor

esai

d qu

estio

ns u

ntil

the

Polic

y is

issue

d an

d co

mes

into

effe

ct. I

/We

unde

rsta

nd th

at th

e Co

mpa

ny m

ay a

void

the

polic

y an

d re

ject

any

clai

m p

ayab

le th

ereu

nder

(whe

ther

in w

hole

or i

n pa

rt) i

n th

e ev

ent o

f a d

elib

erat

e m

isrep

rese

ntat

ion,

misd

escr

iptio

n,

erro

r, om

issio

n or

non

-disc

losu

re o

f fac

t (w

heth

er o

r not

ther

e w

as a

n in

quiry

/que

stio

n ra

ised

pert

aini

ng to

the

sam

e) w

ith o

r with

out a

n in

tent

ion

to d

efra

ud th

e Co

mpa

ny b

y m

e/us

whi

ch w

ould

hav

e aff

ecte

d th

e pr

emiu

m p

ayab

le o

r the

acc

epta

nce

of t

he ri

sk b

y th

e Co

mpa

ny. /

Say

a/Ka

mi m

enge

sahk

an b

ahaw

a sa

ya/k

ami t

elah

mem

beri

sepe

nuh

perh

atia

n un

tuk m

enja

wab

kese

mua

soal

an ya

ng te

rkan

dung

seca

ra ju

jur d

i sep

anja

ng p

enge

tahu

an d

an in

gata

n da

n sa

ya/k

ami a

kan

bert

angg

ungj

awab

unt

uk m

embe

ritah

u pi

hak S

yarik

at te

rhad

ap

seba

rang

per

ubah

an, p

inda

an a

tau

pena

mba

han

pada

soal

an d

i ata

s seh

ingg

a Po

lisi d

ikel

uark

an d

an b

erku

atku

asa.

Say

a/Ka

mi f

aham

bah

awa

Syar

ikat

bol

eh m

emba

talk

an P

olisi

ini d

an

men

olak

seba

rang

tunt

utan

(sam

a ad

a ke

selu

ruha

n at

au se

baha

gian

) sek

irany

a be

rlaku

sala

h ny

ata,

pen

eran

gan

yang

sala

h, ke

silap

an, t

ertin

ggal

ata

u tid

ak m

ende

dahk

an fa

kta

(sam

a ad

a te

rdap

at p

erta

nyaa

n/pe

rsoa

lan

atau

pun

tidak

dik

emuk

akan

men

gena

i yan

g sa

ma)

den

gan

niat

ata

u ta

npa

niat

unt

uk m

enip

u Sy

arik

at o

leh

saya

/kam

i yan

g ak

an m

enje

jask

an p

rem

ium

yang

pe

rlu d

ibay

ar a

tau

terh

adap

pen

erim

aan

risik

o ol

eh p

ihak

Syar

ikat

.

I/We

agre

e th

at th

e Co

mpa

ny s

hall

have

the

right

to u

se m

y/ou

r dat

a an

d pe

rson

al in

form

atio

n fo

r the

pur

pose

of t

he in

sura

nce

oper

atio

nal p

roce

ss w

hich

mig

ht in

clud

e tr

ansf

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mua

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tu a

nak-

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Yes

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Sign

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n :

Cov

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No. P

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Insu

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sura

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to

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Am

Gen

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4191

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A m

embe

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mB

ank

Gro

up

Hea

d O

ffice

: Men

ara

She

ll, N

o. 2

11, J

alan

Tun

Sam

bant

han,

504

70, K

uala

Lum

pur,

Mal

aysi

aPo

stal

Add

ress

: PO

Box

112

28, G

PO

Kua

la L

umpu

r, 50

740

W.P

. Kua

la L

umpu

r, M

alay

sia

(GS

T R

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tratio

n N

o. 0

0078

9741

568)

Cust

omer

Con

tact

Cen

tre

Tel

Call

1 30

0 80

303

0 at

loca

l rat

esG

ener

al li

ne +

603

2268

333

3Em

ail

cust

omer

@am

assu

ranc

e.co

m.m

y

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