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    Motor Insurance Amendment Form - Updated May 2023

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    bibi138913
    This document is an amendment and e-payment form for a motor insurance policy with Allianz General Insurance Company. It requests changes to policy details or cancellation and includes sections for beneficiary details, requests/amendments, beneficiary banking details, declarations, and office use. The applicant must provide accurate contact and bank account information for payment to be credited directly to their account. Allianz will rely on the information provided and will not be liable for losses resulting from invalid or inaccurate details.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Motor Insurance Amendment Form - Updated May 2023

    Uploaded by

    bibi138913
    131 views1 page
    This document is an amendment and e-payment form for a motor insurance policy with Allianz General Insurance Company. It requests changes to policy details or cancellation and includes sections for beneficiary details, requests/amendments, beneficiary banking details, declarations, and office use. The applicant must provide accurate contact and bank account information for payment to be credited directly to their account. Allianz will rely on the information provided and will not be liable for losses resulting from invalid or inaccurate details.

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    Motor Insurance Amendment Form_Updated May 2023

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    This document is an amendment and e-payment form for a motor insurance policy with Allianz General Insurance Company. It requests changes to policy details or cancellation and includes sections for beneficiary details, requests/amendments, beneficiary banking details, declarations, and office use. The applicant must provide accurate contact and bank account information for payment to be credited directly to their account. Allianz will rely on the information provided and will not be liable for losses resulting from invalid or inaccurate details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    131 views1 page

    Motor Insurance Amendment Form - Updated May 2023

    Uploaded by

    bibi138913
    This document is an amendment and e-payment form for a motor insurance policy with Allianz General Insurance Company. It requests changes to policy details or cancellation and includes sections for beneficiary details, requests/amendments, beneficiary banking details, declarations, and office use. The applicant must provide accurate contact and bank account information for payment to be credited directly to their account. Allianz will rely on the information provided and will not be liable for losses resulting from invalid or inaccurate details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Allianz General Insurance Company (Malaysia) Berhad 200601015674 (735426-V)

    Motor Insurance Amendment & E-Payment Form

    Please be informed that payment will be credited directly into your bank account. Thus, the following information provided must be accurate.
    Part 1. Beneficiary Details

    Name of Applicant/Company

    Mailing Address

    NRIC/Passport/Bus. Reg. No Mobile No/Business Tel No

    E-mail Address

    Policy No/Vehicle No Period of Cover

    Part 2 Request/Amendment

    Withdraw NCD entitlement from the above mentioned policy/e-cover note with effect from

    • *Transfer my/our NCD of % with effect from To my/our Vehicle No

    *Cancel the above mentioned policy/e-cover note with effect from


    Reason
    Par Amendment
    a. Insured’s Name
    b. Vehicle No. c. Year of Make
    d. Engine/Chassis No. e. *C.C/Tonnage

    f. Change of Address

    g. Others (please specify)

    Part 3. Beneficiary Banking Details (*to be completed when required)

    Bank Name

    Bank Address/Branch

    Bank Account No.

    Type of Account Savings Current Others (please specify)


    ID captured during opening of bank account NRIC Passport Bus. Reg. No.

    Part 4. Declaration
    Declaration of the vehicle conditions: I/We, the owner/on behalf of the owner of the above vehicle is hereby agreed and declared that is still in good
    condition without any claim/damage prior to my request for the above endorsement.
    I/We hereby declare that all information provide herein is true and complete. I/We understand that Allianz General Insurance Company (Malaysia)
    Berhad (the “Company”) shall rely on the said information and accordingly, I/We shall indemnify the Company for any losses, damages or claims that
    it may suffer or incur as a consequence of relying thereon. I/We also consent to my/our personal data being used, stored, processed or disclosed by
    the Company and its agents to facilitate the performance of such functions by the Company as an insurer.

    Signature of Applicant Company Stamp

    Name Date

    Part 5. For Office Use Only

    Department/Branch Profile Code

    Verified By & Date Approved By & Date

    Notes:
    1. This facility allows payment to be credited into the above mentioned account only.
    2. All relevant fields must be completed and appropriately marked ✓ where applicable. You may type or handwrite your details.
    3. Please attach the following:-
    (i) copy of NRIC or Passport or Business Registration Form, whichever is applicable; and
    (ii) 1st page of (a) your bank statement; or (b) your bank saving book showing the account name and account number; or (c) details of your bank account obtained from your bank’s website that
    has been certified by your bank; or (d) letter from your bank confirming your bank account details;
    (iii) copy of the approval letter from Customs on your SST registration number and effective date of SST registration (if applicable).

    - If the copy of the document mentioned in [3. (i) and (ii)] is not provided, the Company deems that the details provided in this form is valid and accurate. In the event any invalid/inaccurate
    details is provided which results in payment being credited into an unintended bank account or if there is any loss incurred as a result thereof, the said payment made by the Company is still
    deemed as full and final payment and the Company shall be released and fully discharged from all existing and future liabilities, claims and demands in relation to such payment.

    Allianz General Insurance Company (Malaysia) Berhad 200601015674 (735426-V)


    Allianz Arena, Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur,
    Allianz Contact Centre: 1 300 22 5542 Email: [email protected] Updated on 3rd May, 2023

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