Proposal Form Borang Insuran Travel - PDF

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TOKIOMARINE                                                                                                       Agent/Broker
                                                                                                                              FOROFFI(EU5EONLY



                                                                                                                   c r N o .n E n n n n n n

Informationcolleded in this p.ogosalfonn shallbe used in connectionwith the Company'spurposei and courseof business
                                                                                                                  only.
Moklumotyong diperolehi dolomborangcadangonhonyobolehdigunokanolehSyarikotuntuk urusanperniogoonsohoio.
                      di
StatementPursuantto Section149 (4) of the Insurance        Aat 1996- Youareto disclose this proposal
                                                                                      in           form fully and faithfullyall the factswhich you
know or ought to know otherwise policyissued
                                  the               hereunder may be void-
Kenfotoan mengikutseksyen149 (4) Aktot;tutunt | 996 - Anda dlminto mendedohkon     opo-apomoklumatyong anda tahu otauperlu tahu denganlengkap
don benardi dalomborong ini,jika tidok, polisiyang dikeluorkan                ini
                                                             menurutcodongon odoldh tidok soh.

     write in block felle6. silo tulisdengon
Please                                     hurufbesar.




      Nome of lnsurcd Pe$on                          New NRIC No./Bitth Cett, No,
   Nomd Onng Yong Diintu@ntkon                       No. KP (Botu)/No. Siiil Bercnok




ADDRESSAIAMAI

                                                                                                                              POs(OD
                                                                                                                       POSTCODE

        NO.
T:LEPHONE          PEIABAT
              OFFICE                                                       HOME RUMAH                                   H/P TELBIMBIT
NOMBORTELEFON




   l/lLle hercby nominate the following as my/ow nominee(s) Soyo/Komi ingin menomokon nomo-nomo di bowoh,

           Nameof Nominees                                                                         New NRIC No.                                    VoShare
             Nqmq Penomg                                                                            No. KP (Boru)                                 o/o
                                                                                                                                                    Bqhogion
   l.
   2.

        In accordancewith        166
                          Section ofth€ InsumnceAct     1996,Malaysia,
                                                                     nominee(s)  should (a)spouse, childor (c) parcntG) thercis no spouse childatthe time
                                                                                                    (b)
                                                                                       be:                                if                 or
        of making this nomination. nomjnee a muslimpolicyownerupon receipt policymoneys
                                 A         of                                  of             shalldistibute policymoneys accodancewiththe syaridh
                                                                                                            the              in                           law
        Mengikutseksyen                                                            (a)
                                                      penono hendoklohmerupakon: suaniatau istei, (b) anak atou (c) ibubapojiko tidok nenpunyoi suoni dtou bteri
                         166 Aktatnsunns 1996 Maloysio,
        otou onok ketikonenonokon pendno. Penanapenilik polisiberugana lslan seboiknenerino wongpolisihendokloh nengagihkonwongpolisitesebut nengikut Unddng

                                                                                        .   :. i                                                                   $
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Please (y') in appropriate
     tick                     S/o      (t)        yangsesuoi.
                         boxes. tondokon podo petok

PLANTY?E,/fN'JPTAN

O      |ndivtdualPlanPetonIndividu                                           O      Fanity PtanPelansekeluorgo


         DESTINASI
DESTINATION

fourney (if availabfe)Perjolonan(jiko odo)i

Ul     Area 1 KawosonI I Asia
U      Atea2 Kowoson Wodddde excluding USAand CanadaSei.rnrh
                   2:                                      dunia tidak termosuk
                                                                              AmerikaSyarikotdon Kanodo
l)                  3:
       Atea3 Kawasan Worldwide including USAand Ca ada Seluruh             Ameiko Syoikot don Kanado
                                                              dunio termosuk

Q      Twowoy coverPerlindungon hala
                              dua                                            C       One way covetPerlindungansehola

     OF
PERIOD INSURANCE                                         To                                 No. of Days
TEMPOHINSURAN                   Dari                     Hingga                             Bil.Hoi

      INSTRUCTION
PAYMENT              BAYARAN
                ARAHAN
        a
I enclos€ cheque/bankdraft/money Soyo
                                order menyertokon
                                                cek/bonk          wangpos
                                                       drof/kirimon
(No.               ) for urtuk RM            payable boyorkepada
                                                   to            TOKIOMARINE      (M)
                                                                           INSURANS BERHAD

lf payingby creditcard(min. RMl00)./*o memboyor
                                              dengon kredit(min.RM|00)
                                                   kod

Q      vi.u                     O       Maste.ca.d
                             OO
c a r d N o . N o . K o d O OO O C O                 OCOO         COCO                cwNo.No.cyyOOO
     Date   Lupu,OOOO
E.piry Torikh




        of
signature Cardmember         Ahli
                   Tondotangan Kod




I am^Vearc in good health,freefrom physical impairment deformityand I am/we are not travelling the purpose obtainingmedical
                                                       or                                        for            of
treatmentor travellingagainstadviceof any medicalpractitioner.
                                                            l/we understand refundof premiumis grantedoncethe travelcertificate
                                                                           no
is issued.
Soya/Kami  mengokuberododolom keadaankesihatanyong boilt bebosdoripodoketidakempumoonotou kecacatan       fizikol don soyo/kamitidok
melokukan  pe4alononuntuktujuonmendopatkon rowotonperubotonatauperjalanan yongbettentongon   dengonnasihotmona-mona perubotdn.
                                                                                                                       ahli
Saya/Kami  memohomi  bohowo tiodo bayoranbalikpremiumokan dikembolikonsetelohsijilperjalonondikeluotkan.




        of       Iondotongon
Signature Proposer               lnsuron
                           Pemohon                                                                 Date Torikh