Proposal Form - OMG Snatch Protector V3

AXA Affin General Insurance Berhad (23820-W)
Ground Floor Wisma Boustead
71 Jalan Raja Chulan 50200 Kuala Lumpur
 (603) 2170 8282
 (603) 2031 7282
 [email protected]
 www.axa.com.my
Proposal Form
GST Reg. No.:
O.M.G Snatch Protector - Personal Accident Insurance
Date:
IMPORTANT NOTICE
1. 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.
Failure to take reasonable care in answering the questions 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 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.
2. The personal data submitted by and collected from You may be used by Us and/or any member of the AXA Group of companies and/or any of its associated
companies, within or outside of Malaysia, for administration or direct marketing purposes and in this connection, We may transfer or disclose that information
to any of those other companies. We will cease to use the Personal Data for direct marketing purposes if You request Us to do so. For further details, please
refer to Our “Data Privacy Notice” stipulated in Our website.
3. The insurance policy is only valid upon full payment of premiums during submission of this Proposal Form. You are advised to request Your agent/broker for
an official receipt as proof of payment.
4. Cover for Personal Accident Insurance is provided subject to the Company’s usual terms, conditions and exceptions for this type of insurance. A specimen copy
of the policy wording is available on request.
5. No cover is in force until the proposal has been accepted in writing by the Company.
6. Premium charged for this Policy exclude tax(es) that would be imposed in the future (including Goods and Services Tax (“GST”)) and from time to time, We will
be entitled to recover from You any GST or other taxes that We are required by law to collect. For avoidance of doubt, GST on a pro-rata basis will be chargeable
for any period of insurance that falls on or after the implementation date of GST, as applicable.
SPECIAL NOTIFICATION
The Proposer is hereby notified that the Company has appointed Agents/Representatives who have the authority to solicit or negotiate Contracts of Insurance on
behalf of the Company. All authorised Agents/Representatives are issued with authorisation cards.
1. ALL QUESTIONS MUST BE FULLY ANSWERED - TICKS OR DASHES WILL NOT SUFFICE
2. PLEASE WRITE IN BLOCK LETTERS AND IN BLACK INK
3. PLEASE TICK () WHERE APPROPRIATE
A. PARTICULARS OF PROPOSER
Salutation:
Mr
Mrs
Ms
Madam
Dr
Gender*:
Others If others, please specify:
Male
Female
Name* (as in new NRIC/Passport/Company Registered Name):
Correspondence Address*:
Postcode*:
New NRIC/Passport/Co. Registered No.*:
Date of Birth*: dd/mm/yy
Tel. No. (H/P)*:
Tel. No. (Office):
Tel. No. (Home):
Email*:
Ethnic Group:
Nationality*:
Malay
Chinese
Indian
Others
Marital Status*:
Married
Single
Business or Profession/Occupation:
*Required fields
B. PARTICULARS OF SPOUSE TO BE INSURED
New NRIC/Passport*:
Date of Birth*: dd/mm/yy
Gender*:
Male
Female
Business or Profession/Occupation:
*Required fields
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OMGPA/PR (01/16)
Name* (as in new NRIC/Passport):
C. TABLE OF BENEFITS
BENEFITS
PLAN A (RM)
PLAN B (RM)
PLAN C (RM)
Accidental Death
Accidental Death due to Snatch Theft / Robbery
100,000
200,000
150,000
300,000
200,000
400,000
Accidental Permanent Disablement
100,000
150,000
200,000
100
200
300
Accidental Daily Hospital Income
(365 days per accident)
100 per day
150 per day
200 per day
Hospital Income due to Intensive Care Unit
(365 days per accident)
200 per day
300 per day
400 per day
1,000
1,000
1,000
Cash Relief due to Snatch Theft & Robbery
Cash Relief due to Accidental Death or
Accidental Permanent Disablement
D. POLICY PREMIUM
PLAN A
PLAN B
MONTHLY
PREMIUM
Self only
RM 26.50
RM 37.10
RM 47.70
Self + Spouse
RM 47.70
RM 66.78
RM 85.86
ANNUAL
PREMIUM
Self only
RM 318.00
RM 445.20
RM 572.40
Self + Spouse
RM 572.40
RM 801.36
RM 1030.32
Note: Premium rates above are inclusive of 6% GST.
PLAN C
Total Amount Due: RM
Period of Insurance: From dd/mm/yy
To dd/mm/yy
E. NOMINATION
I/We hereby nominate the following as my/our nominee(s) for the O.M.G Snatch Protector Insurance.
Name & Address
Name of Witness:
New NRIC No.
Date of BIrth
Relationship
Share %
Signature of Witness:
(Witness must be aged 18 or above and is not a named nominee under the same policy. (in accordance with subparagraph 2(3) of Schedule 10 of the FSA.))
NOTES ON NOMINATION: (In accordance with Paragraph 5(1), 2(1) & (2), Schedule 10 of the Financial Services Act 2013 (“the FSA”))
1) Any Muslim nominees must receive the policy benefits as executor and not as beneficiary.
2) The spouse/child of married non-Muslim and parents of non-married non-Muslim nominees receive the policy benefits in trust. Only death benefits are
payable to the trustee and written consent of the trustee is required for revoking such a nominee or for varying or surrendering.
3) Any other non-Muslim nominees will be taken as executors and not as beneficiaries.
4) A policy owner should appoint a trustee for the policy money and in the event of failure to do so, the competent nominee shall be the trustee.
5) If the policy owner intends the nominee to receive the policy money as beneficiary and the nominee is not his spouse, child or parent under Paragraph 5,
Schedule 10 of the FSA, then he should assign the policy benefits to the nominee.
6) Nominee(s) must be aged 18 or above.
7) The Proposal Form forms part of the policy contract.
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F. PAYMENT METHOD
I/We wish to pay my premium:
(inclusive of all tax) (“Total Amount Due”)
Below is my payment instruction
Please activate automatic renewal for my policy and charge the Total Amount Due to my Credit Card / Debit Card / Current Account / Savings Account
By Debit Card (Affin Bank, Maybank, RHB, Hong Leong Bank, AmBank)
By Credit Card
Visa
MasterCard
Name of Bank
Card No.
-
-
(inclusive of all tax) (“Total Amount Due”)
Expiry Date:
-
(mm/yy)
:
Cardholder’s Name :
Cardholder’s Signature:
Date: dd/mm/yy
Monthly
RM
-
Annually
RM
-
By Current Account / Savings Account with Affin Bank (applicable to Annual Premium only)
Account No.
By Cheque (applicable to Annual Premium only)
Bank
(inclusive of all tax) (“Total Amount Due”)
Amount (RM)
(inclusive of all tax) (“Total Amount Due”)
Cheque No.
Amount (RM)
G. DECLARATION
I/We hereby declare that the above answers and statements are true, and that I/we have withheld no information whatever regarding this application.
I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we
hereby declare that I/we have fully and accurately answered the questions above.
Signature of Proposer:
Date: dd/mm/yy
H. DECLARATION BY INTERMEDIARY/INSURER
I/We hereby confirm that I/we have sighted the original copy of the NRIC/Passport and verified the identity of the proposer.
Signature of Intermediary/Insurer:
Date: dd/mm/yy
Name:
Account No:
Note: Please attach a copy of the Proposer’s NRIC/Passport where the premium is more than RM50,000.
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