Chubb Travel Insurance
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- Garey Walters
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1 Chubb Travel Insurance Proposal Form / Borang Cadangan Statement Pursuant to Financial Services Act 2013, Schedule 9 Kenyataan Mengikut Akta Perkhidmatan Kewangan 2013, Jadual 9 You have a duty to take reasonable care / Anda mempunyai kewajipan untuk mengambil penjagaan munasabah: (a) not to make a misrepresentation to Chubb Insurance Malaysia Berhad (Chubb) when answering any questions We ask in this proposal form; and / tidak membuat salah nyataan kepada Chubb Insurance Malaysia Berhad (Chubb) apabila menjawab sebarang soalan yang Kami tanya di dalam borang cadangan ini; dan (b) to disclose to Us any matter, other than what We have asked in (a) above, that You know to be relevant to Our decision on whether to accept the risk or not and the rates and terms to be applied. / untuk mendedahkan kepada Kami sebarang perkara, selain daripada apa yang Kami kehendaki dalam (a) di atas, yang Anda tahu sebagai berkaitan dengan keputusan Kami sama ada untuk menerima atau tidak risiko dan kadar dan terma yang akan digunapakai. This duty of disclosure above shall continue until the time the contract is entered into, varied or renewed. / Kewajipan pendedahan di atas akan berterusan sehingga ke masa kontrak itu dibuat, diubah atau diperbaharui. Your duty to take reasonable care for (a) above shall be based on what a reasonable person in your circumstances would have known. / Kewajipan anda untuk mengambil penjagaan munasabah bagi (a) di atas hendaklah berasaskan kepada apa seorang munasabah dalam hal keadaan anda patut tahu. Details of First Named Policy Holder / Butir- Butir Pemegang Polisi *The following are the details of the Insured Person who will act as the policy holder for any policy that may be issued as a result of the proposal form. / Berikut adalah butiran Orang Tertanggung yang akan bertindak sebagai pemegang polisi bagi polisi yang dikeluarkan hasil dari borang cadangan. *Name / Nama *Address of First Named Insured Person / Alamat surat-menyurat bagi Orang Tertanggung Pertama *Post Code / Poskod Tel. No / No. Tel (House / Rumah) Tel. No / No. Tel (Office / Pejabat) Fax. No / No. Faks * / E-mel *Handphone / Telefon Bimbit *Compulsory details required / Maklumat wajib yang diperlukan Page 1 of 5
2 Details of Insured Person(s) / Butir- Butir Orang Tertanggung No. *Name (Please state: Mr/Mrs/Miss/Mdm/Dr) *Nama (Sila nyatakan: Encik/Puan/Cik/Dr) *New IC. No / Passport No. *No K.P Baru / No. Paspot *Date of Birth *Tarikh Lahir Relationship to Policy Holder Hubungan kepada Pemegang Polisi * Compulsory details required / Maklumat wajib yang diperlukan Travel Period / Tempoh Perjalanan Departure Date / Tarikh Berlepas D D - M M - Y Y Y Y Return Date / Tarikh Kembali D D - M M - Y Y Y Y Period of Insurance (Number of Days) Tempoh Insurans (Bilangan Hari) Note / Notis 1. Insured & Spouse / Tertanggung & Pasangan Insured Person and legal spouse that is recognised under the Laws of Malaysia. / Orang Tertanggung dan Pasangan yang sah di bawah undang-undang Malaysia. Family / Keluarga Insured Person, one legal spouse and unlimited accompanying dependent child/children aged minimum 30 days old not more than 18 years of age or not more than 23 years of age and a full time student at a recognized school, college or university and legally dependent on the insured or their spouse. Dependent Child means legally dependent, unmarried children (including step-children and legally adopted children) who are wholly dependent on the insured. / Orang Tertanggung dan Pasangan yang sah dan bilangan anak-anak Tanggungan yang berusia minimal 30 hari dan tidak lebih daripada 18 tahun atau tidak lebih daripada 23 tahun dan seorang pelajar sepenuh masa di sekolah, kolej atau universiti yang diiktiraf. Anak Tanggungan bermaksud seorang anak yang belum berkahwin dan dari segi undang-undang bergantung pada pengambil insurans (termasuk anak tiri dan anak angkat yang sah). 2. Coverage for spouse is equal to the Insured Person's. / Perlindungan bagi suami atau isteri adalah sama dengan Tertanggung. 3. Each child receives the same benefit amount as the Insured Person's except for Personal Accident where each child shall be entitled to receive up to RM 81,250*. / Setiap orang anak akan menerima jumlah dana seperti Orang Tertanggung kecuali untuk Kemalangan Diri di mana setiap orang anak cuma berhak menerima sehingga RM 81,250*. 4. Eligibility / Kelayakan Above 30 days of age, no maximum age limit (Single Trip). / Umur 30 hari dan ke atas, tiada had maksimum umur. Above 18, to below 70 years of age, with policy renewal up to age of 80 (International Annual Policy). / 18 tahun ke atas dan kurang daripada 70 tahun, dengan pembaharuan polisi sehingga 80 tahun (polisi tahunan untuk Pelan Antarabangsa sahaja). 5. A journey/trip shall involve returning to the country of residence within period of insurance (maximum period of any single trip is 183 days for International Plan, 90 days for International Annual Plan and 30 days for Domestic Plan). / Sesuatu perjalanan itu yang melibatkan kepulangan ke negara asal dalam tempoh insurans (tempoh maksimum setiap perjalanan tunggal adalah 183 hari untuk Pelan Antarabangsa, 90 hari untuk Pelan Tahunan Antarabangsa dan 30 hari untuk Pelan Domestik). *Subject to plan / Tertakluk kepada pelan Page 2 of 5
3 Choice of Plan / Pelan Pilihan Please tick accordingly ( ) / Sila tandakan mana yang berkenaan( ) : International / Antarabangsa (Excluding stamp duty / Tidak termasuk duti setem) Per Insured Person Setiap Orang Tertanggung 1-5 Days / Hari RM63 RM86 RM109 RM39 RM56 RM Days / Hari RM79 RM110 RM138 RM57 RM82 RM Days / Hari RM121 RM168 RM212 RM79 RM115 RM140 RM156 RM215 RM272 RM104 RM150 RM183 RM202 RM280 RM353 RM141 RM204 RM249 RM463 RM520 RM540 RM270 RM355 RM370 Insured & Spouse Tertanggung & Pasangan 1-5 Days / Hari RM118 RM164 RM207 RM73 RM105 RM Days / Hari RM150 RM208 RM262 RM108 RM156 RM Days / Hari RM230 RM319 RM403 RM150 RM218 RM265 RM295 RM409 RM516 RM197 RM285 RM347 RM383 RM531 RM671 RM268 RM388 RM472 RM878 RM987 RM1025 RM512 RM674 RM702 Family /Keluarga 1-5 Days / Hari RM156 RM215 RM272 RM96 RM138 RM Days / Hari RM197 RM273 RM345 RM142 RM205 RM Days / Hari RM303 RM420 RM529 RM197 RM286 RM348 RM388 RM538 RM679 RM259 RM375 RM457 RM504 RM699 RM882 RM352 RM510 RM621 RM1156 RM1298 RM1349 RM673 RM886 RM924 Page 3 of 5
4 Domestic / Domestik (Including 6% GST and Excluding stamp duty / Termasuk 6% CBP dan Tidak termasuk duti setem) Per Insured Person Setiap Orang Tertanggung 1-3 Days / Hari RM Days / Hari RM Days / Hari RM Days / Hari RM59.36 RM20.14 RM26.50 RM37.10 RM48.76 Insured & Spouse Tertanggung & Pasangan 1-3 Days / Hari RM Days / Hari RM Days / Hari RM Days / Hari RM RM37.10 RM49.82 RM71.02 RM91.16 Family / Keluarga 1-3 Days / Hari RM Days / Hari RM Days / Hari RM Days / Hari RM RM48.76 RM64.66 RM93.28 RM GST (Goods & Service Tax) / CBP (Cukai Barangan & Perkhidmatan) Payment Instruction / Arahan Pembayaran I authorize Chubb Insurance Malaysia Berhad (Chubb) to debit my account or credit card for payment of premium. / Saya dengan ini membenarkan Chubb Insurance Malaysia Berhad (Chubb) mendebitkan akaun atau kad kredit saya untuk pembayaran premium. Name of Account Holder or Credit Card / Nama Pemegang Akaun atau Kad Kredit: Payment Mode / Kaedah Pembayaran Credit Card / Kad Kredit VISA Mastercard Card No. / No. Kad Card Expiry / Tarikh Tamat Kad Date / Tarikh D D - M M - Y Y Y Y Signature of Cardholder Tandatangan Pemegang Kad Cash / Tunai Cheque / Cek Cheque No. / No. Cek Page 4 of 5
5 Producer Details / Butiran Ejen Agency Code / Kod Agensi : Producer's Code / Kod Ejen : Contact Person / Orang Dihubungi : Declaration / Pengakuan I/We agree that the statements and declarations contained in this proposal form will be relied upon by Chubb to decide whether to accept this insurance. I understand that Chubb needs to deal with my personal data including my sensitive personal data such as details about my health and condition, if any to administer my Policy and offer me insurance products and services. To achieve these purposes, I allow Chubb to collect, use and disclose my personal data to selected third parties in or outside Malaysia, in accordance with Chubb Personal Data Protection Notice, which is found in Chubb s website at I may contact Chubb for access to or correction of my personal data, or for any other queries or complaints. Saya/Kami bersetuju bahawa kenyataan-kenyataan dan pengakuan-pengakuan di dalam borang cadangan ini akan digunapakai oleh Chubb untuk membuat keputusan sama ada untuk menerima insurans ini. Saya faham bahawa Chubb perlu berurusan dengan data peribadi saya termasuklah data peribadi sensitif saya seperti butir-butir mengenai kesihatan dan keadaan saya, sekiranya ada untuk mentadbir Polisi saya dan menawarkan saya produk dan perkhidmatan insurans. Untuk mencapai tujuan-tujuan ini, saya membenarkan Chubb untuk mengumpul, mengguna dan memberi data peribadi saya kepada pihak ketiga terpilih yang terletak di dalam atau di luar Malaysia, selaras dengan Notis Perlindungan Data Peribadi Chubb, yang terdapat dalam laman web Chubb di Saya boleh menghubungi Chubb untuk mendapatkan atau membetulkan data peribadi saya, atau untuk sebarang pertanyaan atau aduan. Signature of the proposer / Tandatangan pencadang Date / Tarikh Notice / Notis For all intents and purpose where there is a conflict or ambiguity as to the meaning in the Bahasa Malaysia provision, it is hereby agreed that the English version shall prevail. Bagi setiap tujuan dan maksud sekiranya terdapat konflik atau kekaburan berkenaan makna di dalam peruntukan Bahasa Malaysia, adalah dipersetujui bahawa versi Bahasa Inggeris akan digunakan. Contact Us / Hubungi Kami Chubb Insurance Malaysia Berhad (formerly known as ACE Jerneh Insurance Berhad) (9827-A) (Licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia) Wisma Chubb 38 Jalan Sultan Ismail Kuala Lumpur Malaysia O F Chubb. Insured ṢM 2016 Chubb. Coverages underwritten by one or more subsidiary companies. Not all coverages available in all jurisdictions. Chubb, its respective logos and Chubb.Insured. SM are protected trademarks of Chubb. Published P1/06/16/V1 Page 5 of 5
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