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
NRIC/Passport/Bus. Reg. No
Mobile No/Business Tel No
Part 2 Request/Amendment
Withdraw NCD entitlement from the above mentioned policy/e-cover note with effect from
*Cancel the above mentioned policy/e-cover note with effect from
g. Others (please specify)
Part 3. Beneficiary Banking Details (*to be completed when required)
ID captured during opening of bank account
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.
Part 5. For Office Use Only
Allianz General Insurance Company (Malaysia) Berhad (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: customer.service@allianz.com.my
Updated on 23 October 2019
Allianz General Insurance Company (Malaysia) Berhad (735426-V)
Motor Insurance Amendment & E-Payment Form
Notes:
1. Please attach copy of NRIC or Passport or Business Registration Form whichever is applicable.
2. Please provide First page of either (a) Beneficiary’s bank statement; or (b) Bank saving book showing the account name and account number; or (c) Details of the Beneficiary’s bank
account obtained from the bank’s website or (d) written confirmation from the bank verifying the bank account details.
- if the copy of document mentioned in (2) not provided, the Company is deemed to have confirmed the account details provided in this form as valid and accurate. In the event of any
invalid/inaccurate account details provided results in payment being credited into a third party bank account or if there is any loss incurred, the payment made thereto is still deemed
as a full payment and Allianz General Insurance Company (Malaysia) Berhad shall be released and fully discharged from all existing and future liabilities, claims and demands in
relation to such payment.