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

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

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.