PENGECUALIANKeadaan sedia ada, kehamilan, bunuh diri, peperangan, melahirkan anak atau keguguran dan kerugian diakibatkan ketika kenderaan digunakan untuk perlumbaan, ujian kelajuan, sewa, perlumbaan rali jalanraya atau semasa pemandu di bawah pengaruh alkohol atau dadah atau memandu tanpa lesen sah.

NOTIS PENTING1. Borang cadangan ini hanya ringkasan saja. Maklumat terperinci

tentang perlindungan polisi boleh didapati di dalam polisi.

2. 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.

3. Liabiliti adalah tidak ditanggung sehingga cadangan ini diterima oleh Syarikat.

4. Sebarang pertukaran informasi yang telah diberi mesti dilaporkan kepada Syarikat serta merta jika tidak Syarikat berhak menolak sebarang liabiliti.

5. Sila berikan jawapan yang tepat kepada setiap soalan. Tanda sengkang adalah tidak memadai.

6. Lampiran Pemberitahuan Produk boleh didapati melalui laman web www.kurnia.com. Anda dinasihatkan untuk membaca Lampiran Pemberitahuan Produk sebelum anda memutuskan untuk mengambil mana-mana produk.

7. Pemegang Polisi adalah dinasihatkan untuk membuat penamaan di bawah Seksyen 130, Akta Perkhidmatan Kewangan 2013 dan boleh mendapatkan Borang Penamaan dari Ibu Pejabat, Cawangan atau Ejen kami.

8. AmGeneral Insurance Berhad dilesenkan di bawah Akta Perkhidmatan Kewangan 2013 dan dikawal selia oleh Bank Negara Malaysia.

9. Versi lengkap Notis Privasi AmGeneral Insurance Berhad boleh didapati di laman web kami di www.amgeneralinsurance.com untuk rujukan lanjut.

10. Sekiranya berlaku konflik atau percanggahan berhubung peruntukan teks Bahasa Inggeris dengan mana-mana Dokumen Kontrak dan apa-apa terjemahannya, maka teks Bahasa Inggeris akan diguna pakai.

EXCLUSIONSPre-existing conditions, pregnancy, suicide, war risks, childbirth or miscarriage and losses incurred while the vehicle is used for racing, speed-testing, hire, road rally or whilst the driver is under the influence of alcohol or drugs or driving without a valid licence.

IMPORTANT NOTICE 1. This proposal form is a brief description only. The full details of the

policy coverage are to be found in the policy.

2. Statement pursuant to Financial Services 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 rates and terms to be applied.

3. Liability does not attach until the proposal has been accepted by the Company.

4. Any changes in the information given must be reported to the Company immediately otherwise the Company may reserve the right to decline all liability.

5. Please give a definite answer to each question, dashes are not sufficient.

6. Product Disclosure Sheet (PDS) can be obtained through our website www.kurnia.com. You are advised to read the PDS before you take out any product.

7. Policy Owners are advised to make a nomination pursuant to Section 130 of the Financial Services Act 2013 and can obtain a Nomination Form from our service counters at our Head Office, Branches or Agents.

8. AmGeneral Insurance Berhad is licensed under Financial Services Act 2013 and regulated by Bank Negara Malaysia.

9. A full version of the Privacy Notice of AmGeneral Insurance Berhad is available on our website at www.amgeneralinsurance.com for your further reference.

10. In the event of a conflict or discrepancy between the provisions of the English text of any of the Contract Documents and any translations thereof, the English text shall prevail.

TABLE OF BENEFITS / JADUAL FAEDAH

Item /Perkara Benefits / Faedah

Medical Expenses (per person) / Perbelanjaan Perubatan (setiap orang)

Corrective Dental and/or Cosmetic Surgery (per person) / Pembedahan Pembetulan Gigi dan/atau Pembedahan Kosmetik (setiap orang)

Ambulance Fees (per person) / Yuran Ambulan (setiap orang)

3

Taxi and Car Rental Expenses / Perbelanjaan Sewa Teksi dan Keretai. Taxi Expenses / Perbelanjaan Teksi ii. Car Rental Expenses up to RM150 per day / Perbelanjaan Sewa Kereta sehingga RM150 sehari(Maximum per incident and limited to 3 reimbursements a year) / (Maksimum setiap kejadian dan bayaran balik terhad kepada 3 kali setahun)

12

Referral Assistance Program Within Malaysia - Taxi and Car Rental Assistance, Arrangement for Hotel Accommodation, Arrangement for Emergency Evacuation, Referral to Service Centre and Car Rental Company and Emergency Message Transmission / Program Bantuan Rujukan Di Dalam Malaysia - Bantuan Sewa Teksi dan Kereta, Pengurusan untuk Penginapan Hotel, Pengurusan untuk Pemindahan Kecemasan, Rujukan ke Pusat Servis dan Syarikat Sewa Kereta dan Penghantaran Pesanan/Mesej Kecemasan

Compassionate Cover For Smash And Grab / Perlindungan Ehsan untuk Samun dan Pecah Tingkapi. Window and/or Windscreen Broken / Tingkap dan/atau Cermin Kereta Pecahii. Loss or Damage to Personal Effects and/or Loss of Cash / Kehilangan atau Kerosakan Barangan Peribadi dan/atau Kehilangan Wang Tunai

Car Loan Protection / Perlindungan Pinjaman Kereta

15

16

17

Private Vehicle / Kenderaan Persendirian

A Driver and up to 4 passengers / Seorang Pemandu dan sehingga 4 penumpang

Each additional passenger / Setiap penumpang tambahan

Note : Premiums stated are inclusive of 6% Goods and Services Tax / Nota : Premium yang dinyatakan adalah termasuk 6% Cukai Barang dan Perkhidmatan (GST)

88.00

8.48

137.80

12.72

243.80

24.38

349.80

37.10

Compassionate Flood Expenses (any one incident/in aggregate any one period of insurance) / Perbelanjaan Ehsan Akibat Banjir (maksimum setiap kejadian/agregat bagi setiap tempoh insurans)6

Compassionate Allowance for Vehicle Total Loss due to Vehicle Collision or Theft / Elaun Ehsan Bagi Kerugian Penuh/Menyeluruh Kenderaan Akibat Perlanggaran Atau Kecurian KenderaanPays an amount equivalent to 10% of Named Vehicle’s Motor Comprehensive or Third Party, Fire and Theft Sum Insured and benefit is only payable if the Motor Comprehensive or Third Party, Fire and Theft Policy is insured with AmGeneral (maximum per incident) / Membayar nilai bersamaan 10% daripada Jumlah Diinsuranskan ke atas Polisi Motor Komprehensif atau Pihak Ketiga, Kebakaran dan Kecurian bagi Kenderaan yang Dinamakan dan faedah akan dibayar jika Polisi Motor Komprehensif atau Pihak Ketiga, Kebakaran dan Kecurian diinsuranskan dengan AmGeneral (maksimum setiap kejadian)

11

Vehicle Breakdown Assistance and Towing Service Within Malaysia (per incident) - Including Unlimited Toll Charges incurred / Perkhidmatan Bantuan Kerosakan Kenderaan dan Perkhidmatan Tunda Di Dalam Malaysia (setiap kejadian) - Termasuk Caj Tol Tanpa Had9

Accidental Death (per person) / Kematian Akibat Kemalangan (setiap orang)1

Permanent Disablement (per person) / Hilang Upaya Kekal (setiap orang)2

Hospital Income (per person, up to maximum 60 days per year) / Pendapatan Hospital (sehingga maksimum 60 hari setiap tahun setiap orang)4

Bereavement Allowance (per person) / Elaun Pengkebumian (setiap orang)Sum Insured doubled if Insured suffers death due to Ebola, SARS, Japanese Encephalitis, Chikungunya, Malaria and Dengue (provided it is not a declared pandemic in Malaysia) / Jumlah Diinsuranskan berganda jika Pihak Diinsuranskan meninggal dunia akibat Ebola, SARS, Ensefalitis Jepun, Chikungunya, Malaria dan Denggi (dengan syarat ia bukan wabak yang diisytiharkan di Malaysia)

5

Car Replacement Expenses (up to RM150 per day, maximum per incident) / Perbelanjaan Gantian Kereta (sehingga RM150 sehari, maksimum setiap kejadian)10

Hotel Accommodation Expenses for vehicle breakdown in Malaysia up to RM150 per night (maximum per incident and limited to 3 reimbursements a year) / Perbelanjaan Penginapan Hotel bagi Kerosakan Kenderaan di Malaysia sehingga RM150 semalam (maksimum setiap kejadian dan bayaran balik terhad kepada 3 kali setahun)13

Hotel Accommodation Expenses for Vehicle Breakdown in Singapore up to RM150 per night (maximum per incident and limited to 3 reimbursements a year) / Perbelanjaan Penginapan Hotel bagi Kerosakan Kenderaan di Singapura sehingga RM150 semalam (maksimum setiap kejadian dan bayaran balik terhad kepada 3 kali setahun)14

Outstanding Credit Card Balance (applicable for Insured only, up to maximum) / Baki Kad Kredit Tertunggak (untuk Pihak Diinsuranskan sahaja, sehingga maksimum) 7

Double Indemnity During A National Public Holiday in Malaysia (per person) / Indemniti Berganda Ketika Cuti Umum Seluruh Malaysia (setiap orang)8

Plan / Pelan A

2,000 peraccident /

setiap kemalangan

Taxi / Teksi - 60Car Rental /

Sewa Kereta - 400

Included / Termasuk

1,500

8,000

5,000

1,000500

Unlimited distance / Tiada

had jarak

30,000

30,000

50 per day / sehari

750

600

400

300

500

60,000

Plan / Pelan 88

Sum Insured / Jumlah Diinsuranskan (RM)

1,500 peraccident /

setiap kemalangan

Not applicable / Tidak berkenaan

Not applicable / Tidak berkenaan

1,500

6,000

5,000

1,000500

Up to 600 km roundtrip /

sehingga 600km pergi balik

15,000

15,000

30 per day / sehari

750

450

Not applicable / Tidak berkenaan

Not applicable / Tidak berkenaan

300

30,000

3,000 peraccident /

setiap kemalangan

Taxi / Teksi - 60Car Rental /

Sewa Kereta - 400

Included / Termasuk

1,500

12,000

5,000

1,000500

Unlimited distance / Tiada

had jarak

Plan / Pelan B

75,000

75,000

75 per day / sehari

750

750

400

300

1,000

150,000

4,000 peraccident /

setiap kemalangan

Taxi / Teksi - 60Car Rental /

Sewa Kereta - 400

Included / Termasuk

1,500

18,000

5,000

1,000500

Unlimited distance / Tiada

had jarak

Plan / Pelan C

120,000

120,000

100 per day / sehari

750

900

400

300

1,500

240,000

Annual Premium / Premium Tahunan (RM)(RM) (RM) (RM)

1017

UW-NM-F415

www.kurnia.comKunjungi ejen & cawangan kami 1-800-88-6333 www.kurnia.comVisit our agents & branches

car loanprotection

smash andgrab cover

PERFECT RIDER PLUS

1-800-88-6333

Drive with peace ofmind for only RM88 p.a. Dengan hanya RM88 setahun,kini anda boleh pandu dengan tenang.

PERFECT RIDER PLUS PERFECT RIDER PLUSRoad accidents can happen anytime. Let PERFECT RIDER PLUS take care of your worries. While you are out driving or riding, boarding or alighting from the named vehicle, rest assured both driver and passengers are protected.

Unique Features

• Affordable Premium for as low as RM88 per year.

• 24 hours Vehicle Breakdown Assistance and Towing Service within Malaysia including Unlimited Toll Charges. For Assistance to contact 24 hours toll free number 1-800-88-6333.

• Children enjoy the same limit as adult on applicable benefits.

• Double Indemnity during a national public holiday in Malaysia.

• Bereavement Allowance - Sum Insured doubled if Insured (Policyholder) suffers death due to Ebola, SARS, Japanese Encephalitis, Chikungunya, Malaria and Dengue.

• Compassionate Allowance for Vehicle Total Loss due to Vehicle Collision or Theft (covered if Named Vehicle’s Motor Comprehensive or Third Party, Fire and Theft Insurance is insured with AmGeneral).

• Compassionate Flood Expenses.

• Compassionate Cover For Smash And Grab.

• Car Loan Protection.

Kemalangan jalan raya boleh berlaku pada bila-bila masa. Pilihlah PERFECT RIDER PLUS untuk menjaga kebimbangan anda. Semasa anda memandu atau menumpang, menaiki atau turun dari kenderaan yang dinamakan, yakinlah kedua-dua pemandu dan penumpang dilindungi.

Ciri-Ciri Unik

• Premium serendah RM88 setahun.

• 24 Jam Perkhidmatan Bantuan Kerosakan Kenderaan dan Perkhidmatan Tunda di dalam Malaysia, termasuk Caj Tol Tanpa Had. Panggilan ke talian bebas tol bernombor 1-800-88-6333 untuk Khidmat Bantuan.

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

• Indemniti Berganda ketika cuti umum seluruh Malaysia.

• Elaun Pengkebumian - Jumlah Diinsuranskan berganda jika Pihak Diinsuranskan (Pemegang Polisi) meninggal dunia akibat Ebola, SARS, Ensefalitis Jepun, Chikungunya, Malaria dan Denggi.

• Elaun Ehsan bagi Kerugian Penuh/Menyeluruh Kenderaan Akibat Perlanggaran atau Kecurian Kenderaan (dilindungi jika Polisi Motor Komprehensif atau Pihak Ketiga, Kebakaran dan Kecurian Kereta Dinamakan diinsuranskan dengan AmGeneral).

• Perbelanjaan Ehsan Akibat Banjir.

• Perlindungan Ehsan untuk Samun dan Pecah Tingkap.

• Perlindungan Pinjaman Kereta.

Eligibility

• Private Vehicle Owners aged 17 years and above.

Kelayakan

• Pemilik Kereta Persendirian berumur 17 tahun dan ke atas.

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g pe

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ibay

ar a

tau

terh

adap

pen

erim

aan

risik

o ol

eh p

ihak

Sya

rikat

.I/W

e ag

ree

that

the

Com

pany

sha

ll ha

ve t

he r

ight

to

use

my/

our

data

and

per

sona

l inf

orm

atio

n fo

r th

e pu

rpos

e of

the

insu

ranc

e op

erat

iona

l pro

cess

w

hich

mig

ht in

clud

e tr

ansf

er o

f dat

a an

d pe

rson

al in

form

atio

n to

the

Com

pany

’s re

late

d co

mpa

nies

, sub

sidi

arie

s an

d/or

its

hold

ing

com

pany

, out

sour

cing

pa

rtne

rs, R

e-in

sure

rs a

nd s

olic

itor b

ut n

ot li

mite

d to

affi

liate

com

pani

es in

clud

ing

thei

r out

sour

cing

par

tner

s. /

Saya

/Kam

i ber

setu

ju b

ahaw

a pi

hak

Syar

ikat

be

rhak

unt

uk m

engg

unak

an d

ata

dan

mak

lum

at p

erib

adi s

aya/

kam

i bag

i tuj

uan

pem

pros

esan

ope

rasi

insu

rans

yan

g m

ungk

in te

rmas

uk p

emin

daha

n da

ta d

an

mak

lum

at p

erib

adi k

epad

a Sy

arik

at ya

ng se

kutu

den

gan

piha

k Sy

arik

at, a

nak-

anak

syar

ikat

dan

/ata

u sy

arik

at in

dukn

ya d

an se

mua

raka

n ko

ngsi

pem

beka

lan

luar

, Pe

nang

gung

Insu

rans

Sem

ula

dan

pegu

am ca

ra te

tapi

tida

k te

rhad

kep

ada

syar

ikat

-sya

rikat

seku

tu te

rmas

uk se

mua

raka

n ko

ngsi

pem

beka

lan

luar

.I/W

e fu

rthe

r agr

ee th

at th

e Co

mpa

ny, i

ts p

artn

ers

and

its re

late

d co

mpa

nies

, sub

sidi

arie

s an

d/or

its

hold

ing

com

pany

can

sha

re a

nd u

se m

y/ou

r dat

a an

d pe

rson

al in

form

atio

n fo

r th

e pu

rpos

e of

pro

mot

ing

the

Com

pany

’s an

d its

rel

ated

com

pani

es’,

subs

idia

ries’

and/

or it

s ho

ldin

g co

mpa

ny’s

prod

uct,

new

se

rvic

es a

nd s

uppo

rt r

equi

rem

ent;

and

mar

ketin

g ca

mpa

igns

and

act

iviti

es a

nd c

omm

erci

al t

rans

actio

ns. /

Say

a/Ka

mi s

eter

usny

a be

rset

uju

baha

wa

piha

k Sy

arik

at, r

akan

nia

gany

a da

n sy

arik

at-s

yarik

at se

kutu

, ana

k-an

ak sy

arik

at d

an/a

tau

syar

ikat

indu

k be

rhak

unt

uk b

erko

ngsi

dan

men

ggun

akan

dat

a da

n m

aklu

mat

pe

ribad

i say

a/ka

mi b

ertu

juan

unt

uk m

empr

omos

ikan

pro

duk,

per

khid

mat

an b

aru

dan

kepe

rluan

soko

ngan

; dan

akt

iviti

uru

s nia

ga k

omer

sil y

ang

dike

ndal

ikan

ol

eh p

ihak

Sya

rikat

dan

sem

ua sy

arik

at se

kutu

ana

k-an

ak sy

arik

at d

an/a

tau

syar

ikat

indu

k.

/

/

/

/

Dat

eTa

rikh

Sign

atur

e of

Pro

pose

r / T

anda

tang

an P

enca

dang

Yes

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N

o / T

idak

For A

gent

/ St

aff U

se O

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uk E

jen

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itang

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ahaj

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Com

plia

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Sec

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16(2

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Ant

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usin

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aut

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y m

e at

the

Poin

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ale.

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enur

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eksy

en 1

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Ak

ta P

ence

gaha

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ngub

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hold

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!