Policy Amendment Form For Office Use Only Service Incident No Personal Lines Motor Personal Property PLUS Accident & Health 01 Individual 05 Individual Travel 02 Group 08 Worksite Marketing 03 Direct Marketing 09 Corporate Travel Policy Details Policyholder/Insured Name Policy No Expiry Date Vehicle Registration No Producer Details Producer Name: Code: Contact No. Kindly endorse policy to reflect the changes indicated below. Effective Date Date Month Year Policy Amendments Increase/Decrease sum insured to RM_________________________________________________________________ Change of plan/occupation class from _____________________________ to __________________________________ Extend period of insurance to expire on ________________________________________________________________ For Motor Policy (extension not exceeding 6 months) Vehicle Registration Card enclosed? Yes No Cancellation of policy Reason: _________________________________________________________________________________________ For Motor Policy: For your attention, I am/We are enclosing herewith the following document(s): Original certificate of insurance; or Declaration of loss of certificate of insurance witnessed by a commissioner for oaths Refund premium: Via GIRO Account (If this is selected please complete page 3) Via cheque, mail to Customer’s correspondence address stated in policy Customer’s alternative address (Please state below if different from policy mailing address) Change policyholder/insured details / Other(s) Type Details 1 of 3 Copyright © AIG Malaysia Insurance Berhad. All rights reserved. Policy Amendment Form_Feb 2014 Below applicable for A&H Group policy only Addition/Deletion of employee(s) (Please attach list of employee) Change of category of employee(s) (Please attach list of employee category) Below applicable for Motor policy only Reinstatement/Inclusion/Deletion of additional coverage: All Drivers L.L.P. for Acts of Negligence S.R.C.C. Windscreen cover @ RM_________________________ Transfer the rights and benefits of my/our policy to: Name: Relationship to insured: NRIC: DOB: Driving Experience: Occupation: Marital Status: Gender: Inclusion of one named driver: Name: Relationship to insured: NRIC: DOB: Driving Experience: Occupation: Marital Status: Gender: Transfer NCD entitlement from the above policy to vehicle no. _____________ under cover no./policy no. ______________ Withdraw NCD entitlement from the above policy Issue NCD confirmation letter (overseas) I hereby authorized Mr/Mrs. __________________________________________ NRIC No ___________________ to act/collect on my behalf:NCD confirmation NCD confirmation letter (overseas) Policyholder’s/Insured’s Signature/Company Stamp Name: Contact No: Date: For Office Use Only Referral to Underwriter *: Yes No Premium computation (to be completed by Front Counter): * please refer to Appendix 1 – Policy Amendment Form Underwriter’s Comments: Prepared by: ___________________________ Approved by: _____________________________ Date: _________________ 2 of 3 Copyright © AIG Malaysia Insurance Berhad. All rights reserved. Policy Amendment Form_Feb 2014 (Note: If space provided is insufficient, please attach advice in a separate sheet.) Bank Account No details (GIRO) Name * NRIC (New) * - - NRIC (Old) * Business Registration Number * - Telephone number * Bank Account number * Current Account Saving Account Email Address * Identification Number or Business Registration Number must exactly match the records as per your saving or current account. Kindly tick issuing bank: LIST OF CONVENTIONAL BANKS Bank Branch Code Code Bank Name PHBM MYKL AFFIN BANK BERHAD AGOB MYK1 AGRO BANK MFBB MYKL ALLIANCE BANK MALAYSIA BERHAD ARBK MYKL AMBANK BERHAD BKRM MYK1 BANK KERJASAMA RAKYAT BMMB MYKL BANK MUAMALAT MSIA BHD BOFA BSNA CIBB CITI DEUT ICBK MY2X MYK1 MYKL MYKL MYKL MYKL HLBB MYKL HBMB CHAS KFHO MBBE OCBC PBBE RHBB SCBL MYKL MYKX MYKL MYKL MYKL MYKL MYKL MYKX SMBC MYKL ABNA UOVB BOTK MYKL MYKL MYKX BNPA MYKL BANK OF AMERICA BANK SIMPANAN NASIONAL BHD CIMB BANK BERHAD CITIBANK BERHAD DEUTSCHE BANK (MALAYSIA) BHD INDUSTRIAL & COMMERCIAL BANK OF CHINA (MALAYSIA) BHD HONG LEONG BANK BERHAD LIST OF ISLAMIC BANKS Bank Branch Code Code Bank Name AIBB MYKL AFFIN ISLAMIC BANK BERHAD ALSR MYK1 ALLIANCE ISLAMIC BANK BERHAD AISL MYKL AMISLAMIC BANK BERHAD BIMB MYKL BANK ISLAM MALAYSIA BERHAD CTBB MYKL COMMERCE TIJARI BANK BERHAD RJHI MYKL AL-RAJHI BANKING & INVESTMENT CORPORATION (MALAYSIA) BHD HLIB MYKL HONG LEONG ISLAMIN BANK BERHAD HMAB MYKL HSBC AMANAH MALAYSIA BERHAD MBIS MYKL MAYBANK ISLAMIC BERHAD OABB MYKL OCBC AL-AMIN BANK BERHAD PIBE MYK1 PUBLIC ISLAMIC BANK BERHAD RHBA MYKL RHB ISLAMIC BANK BERHAD SCSR MYK1 STANDARD CHARTERED SAADIQ BERHAD HSBC BANK MALAYSIA BERHAD J.P. MORGAN CHASE BANK BERHAD KUWAIT FINANCE HOUSE (M) BHD MALAYAN BANKING BERHAD OCBC BANK MALAYSIA BHD PUBLIC BANK BERHAD RHB BANK BERHAD STANDARD CHARTERED BANK MALAYSIA BERHAD SUMITOMO MITSUI BANKING CORP MY BHD THE ROYAL BANK OF SCOTLAND BHD UNITED OVERSEAS BANK BHD BANK OF TOKYO-MITSUBISHI UFG (MALAYSIA) BERHAD BNP PARIBAS MALAYSIA BERHAD Policyholder’s/Insured’s Signature/Company Stamp Name: Date: 3 of 3 Copyright © AIG Malaysia Insurance Berhad. All rights reserved. Policy Amendment Form_Feb 2014
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