Address: Level 36, Menara Bangkok Bank, 105, Jalan Ampang, 50450 Kuala Lumpur.
Address: Xxxxx 00, Xxxxxx Xxxxxxx Bank, 000, Xxxxx Xxxxxx, 00000 Xxxxx Xxxxxx.
Toll Free: 0-000-000-000 Tel.: 00-0000 0000 Fax: 00-0000 0000 E-mail: xxxx@xxxxxx.xxx.xx Website: xxx.xxxxxxxxxxxx.xxx.xx
Postcode | ||||||||||||||||||||||||||||||||||
PERSONAL ACCIDENT INSURANCE PROPOSAL FORM
Berjaya Sompo Insurance Berhad (62605-U) (BSIB) is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia. | |||||||||
IMPORTANT NOTICE | |||||||||
Consumer Insurance Contract Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for purposes unrelated to your trade, business or profession, you have a duty to take reasonable care not to make a misrepresentation in answering the questions in this proposal form. You must answer the questions in this proposal form fully and accurately, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure for Consumer Contract shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in this proposal form, you are required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this proposal form is inaccurate or has changed. | |||||||||
PLEASE USE BLOCK LETTERS AND CROSS (X) IN APPROPRIATE BOX | |||||||||
Agency : | Account No. : | Product Name : | |||||||
DETAILS OF PROPOSER | |||||||||
Name of Proposer (in full) : | |||||||||
Address (Postal): | |||||||||
Telephone No | Email : | ||||||||
New NRIC No.: | Nationality : | ||||||||
Occupation : | |||||||||
Period of insurance : From : To: (Both Dates Inclusive) | |||||||||
Duties involve : ⬜ Administrative ⬜ Supervisory ⬜ Manual | |||||||||
DETAILS OF INSURED PERSON | |||||||||
No | Name of insured Person | NRIC | Relationship | Occupation | Date of Birth | Sex | Class | Plan | Premium |
(ULTIMAPA/PF092018) 1
1. Are you or any persons to be insured have any Personal Accident or Life Insurance with the Company or elsewhere? ⬜ Yes ⬜ No If "Yes", please give details of Name of Company, Policy Number and Sum Insured? |
2. Do you or any person to be insured engage in any hazardous sport or activities involving additional risk or accident? ⬜ Yes ⬜ No Give details if cover against such risk is required. |
3. Do you or any person to be insured have any physical defects or suffer from infirmity? ⬜ Yes ⬜ No If "Yes", please give details. |
4. During the last five years, did you or any persons to be insured sustain any injury or receive medical or surgical treatment which have prevented you or them from attending to you or their normal occupatoi n,pursuits or business for a period of 7 days or longer? ⬜ Yes ⬜ No If "Yes", please give detai ls. a) Type of injury or medical treatment b) Claim made against any company. Please state nane of company, Policy Number and claim amount. |
5. Are you or any person to be insured workingoutside Malaysia? ⬜ Yes ⬜ No If "Yes", please state the country and for how long? |
6. Have you or any person to be insured ever had an application for life or PersonlaAccident Insurance declined or accepted with Sum Insured reduced or the renewal premium increased? ⬜ Yes ⬜ No If "Yes", please give details. |
7. Are you or any person to be insured involved in providing loan or credit facilities (licensed or otherwise), debt collection or any unlawful business activities? ⬜ Yes ⬜ No If "Yes", please give details. |
8. Have you or any person to be insured ever used any habit forming drugs or narcotic or Alcohol excessively or been treated for alcoholismor drughabits? ⬜ Yes ⬜ No If "Yes", please give details. |
9. Will any of the person to be included in the insurance use machinery? ⬜ Yes ⬜ No If "Yes", please give details. |
NOMINEES & TRUSTEE |
IMPORTANT NOTICE Pursuant to Schedule 10 of Financial Act 2013 ("FSA 201 3" ) A policy owner who has attained the age of sixteen (16) years may nominate a natural person to receive pol icy moneys payable under his life policy upon his death./ Pemegang polisi yang telah mencapai umur xxxx xxxxx (16) tahun boleh menamakan sesiapa sahaja untuk menerima wang polisi yang akan dibayar di bawah polisi hayat tersebut atas kematiannya. It is advisable to appoint at least one nominee and keep the nominee informed of the appointment in order to facilitate the payment of policy moneys payable upon death of the Life Insured. Failure to make a nomination may delay the payment of the policy moneys become payable. If you are a non-Muslim policy owner, when you appoint your spouse, child or parent (if you have no spouse or child living at the date of making the nomination) as the nominee, you will create a trust of policy moneys payable upon your death in favor of the nominee. You are advised to appoint a trustee for the policy moneys and in the event of failure to do so, the competent nominee shall be the trustee. For a policy with such trust created, written consent of the trustee is required before you change the nomination, vary, surrender, assign or pledge the policy. Any nominee who is other than the spouse, child or parent (if there is no spouse or child living at the date of nomination) of a non-Muslim policy owner, shall receive the policy moneys payable upon death of the policy owner as an executor. If then policyowner's intention is for such nominee to receive the policy moneys solely as beneficiary i.e. not as an executor, then the policy owner must assign the benefits of the policy to such nominee. |
Policy No : Life Insured : |
APPOINTMENT OF NOMINEES | ||||||||||
I the insured/Proposer hereby nominate the following nominee(s) for the above policy (s) and revoke all existing nominees (if any) named earlier.I also agree that unless revoked by me in writing the nomination made here in shall continue to apply to every renewal of this policy. | ||||||||||
Name of Nominee(s) | I.C No or B.C No | Date of Birth | Address | Relationship | Share(%) | |||||
Signature of witness | Signature of insured /Proposer | |||||||||
Name: | N | ame: | ||||||||
IC No.: | IC | No. : | ||||||||
Address : | Add | ress : | ||||||||
Note : The witness must be at least 18 years of age and cannot be a named nominee under section 163(2) of the insurance Act 1996. | ||||||||||
PAYMENT METHOD | ||||||||||
Total Premium Paid: RM | Please select payment method. | |||||||||
⬜ Cash | ||||||||||
⬜ JomPay | For payment via JomPay, please provide proof of payment. | |||||||||
⬜ Visa ⬜ MasterCard | Card No. - - - | Expiry Date m m / y y | ||||||||
Cardholder’s Name: | ||||||||||
Date: | Car | dholder’s Signature: |
| |||||||
SERVICE TAX (ST) - ST will be imposed on the applicable portion of the premiums due and payable. | ||||||||||
PRIVACY NOTICE | ||||||||||
The personal information including your personal, policy and financial details ("Personal Data") provided by and collected from you may be used and processed by us and our Group Companies1 (within or outside Malaysia) in order for us to provide our services and to operate and manage our function as an insurance company. By signing on this proposal form, you consent to the use and processing of your Personal Data for the purposes as stated in our Privacy Notice. If you represent a body corporate, you have procured the necessary consent for our use and processing of the Personal Data provided by you for the purposes as stated in our Privacy Notice. Please refer to the Privacy Notice for details of your Personal Data privacy rights and our rights of disclosure, which is also available at our website at xxx.xxxxxxxxxxxx.xxx.xx. | ||||||||||
OPTION TO SUBSCRIBE TO CROSS-SELLING ACTIVITIES | ||||||||||
You can extend your consent for us to use your Personal Data for cross-selling purposes within/with our Group Companies or our strategic business partners or selected third parties, by selecting: ⬜ Yes ⬜ No Take note that you can always choose to opt out of the cross-selling activities as described above (including marketing campaigns by any of our Group Companies) at any time by contacting BSIB at the contact number stated above. Note: 1Group Companies refer to Sompo Holdings Group and Berjaya Group, of which BSIB is also an affiliate. | ||||||||||
DECLARATION BY PROPOSER | ||||||||||
I/We declare and warrant that the answers/information provided in this proposal form are true and correct and I/We have not withheld any information or made any misrepresentation likely to affect the acceptance of this proposal and declaration which I/We agree shall be the basis of the contract between myself/ourselves and the Company. I/We shall undertake to notify the Company when there is any subsequent change to the information provided in this proposal form. A copy of the product disclosure sheet (“PDS”) is available at our website xxx.xxxxxxxxxxxx.xxx.xx. Please make sure that you have read and understood the contents of the PDS before purchasing the product. | ||||||||||
Date | Proposer’s Signature | |||||||||
(If the Proposer is a company, authorised signature(s) and chop) | ||||||||||
FOR AGENT / OFFICE USE |
Cover Note / Policy No.: |
Intermediary: |
Account No.: |
Remarks: |