CONFIRMATION OF PURCHASE OF TAKAFUL

E-C/Note No : T67713K-24027887
Issue Date & Time : 30 JUN 2024 01:28:31pm
Period of Takaful : From 30 JUN 2024 To 29 JUN 2025
Vehicle Registration No. : JPK8427
Make of Vehicle : YAMAHA 135LC MY2013 4 SPEED ROTARY
Engine No. : G399EE116844 Chassis No. : PMYKG0540D0116844
Capacity : 134 CC Year of Make : 2013
Participant Name : KHAMIS BIN DOLE
Address : T/L4 KAMPUNG PARIT LAHAK DARAT,MUKIM 6 TONGKANG PECHAH BATU,PAHAT
JOHOR,83010,BATU PAHAT,JOHOR DARUL TAKZIM
NRIC/Business Reg No. : 580611-01-5089
Type of Cover : V-TP MOTOR THIRD PARTY
Product : MOTORCYCLE FOR PRIVATE USE
HP Owner : N/A
Sum Covered (RM) : 0
Transaction Type : New
Claims Excess : RM0.00

Sum Covered (RM) 0 Contribution (RM) 50.70

Loading % 100.00 % Loading Amount (RM) 50.70
All Rider (Y/N) Y All Rider Amt (RM) 50.70
NCD % 25.00 % NCD Amt (RM) 38.03

Basic Net (RM) 114.07

Tuition Load % 0% Tuition Load Amt (RM) 0.00

Extra Coverage (RM) 0.00

SST 8.00 % SST (RM) 9.13

Stamp Duty (RM) 10.00
PT Voucher (RM) 0.00

Act Contribution (RM) 104.85 Payable Amount (RM) 133.20

Extra Benefits Extra Covered (RM) Extra Contribution (RM)

ALL RIDERS 0 0.00

Named Drivers
ALL RIDERS

Agent : T67713K-000 USAHA BJ SDN BHD

Tel No : 016-6999129

THIS IS A COMPUTER GENERATED FORM, SIGNATURE IS NOT REQUIRED. Page 1 of 1

 MOTORCYCLE
MOTORSIKAL
THE SCHEDULE JADUAL
ORIGINAL COPY SALINAN ASAL

Agent Code (Kod Ejen) : T67713K-000 (KUALA LUMPUR) Date (Tarikh) 30 JUN 2024
USAHA BJ SDN BHD Receipt No.
(No. Resit)
Replacing Cover Note No. : T67713K-24027887
(Menggantikan Nota Lindung No.) ACT (ACT) : RM 104.85
Certificate No. (No. Sijil) : 222450185897-00 Basic Contribution : RM 50.70
Loading:100.00% : RM 50.70
The Participant : KHAMIS BIN DOLE
(Peserta)
All Riders : RM 50.70
Address (Alamat) : T/L4 KAMPUNG PARIT LAHAK DARAT, MUKIM 6
TONGKANG PECHAH BATU,PAHAT JOHOR NCD:25.00% : RM 38.03
83010 BATU PAHAT, JOHOR DARUL TAKZIM
Business Reg. No. (No. Sykt.) : Extra Cover : RM 0.00
I/C No. New (No. K/P Baru) : 580611-01-5089 Old I/C No.(No. K/P Lama) :
Business / Profession (Perniagaan / Pekerjaan) : OTHERS
Gross Contribution : RM 114.07
Hire Purchase Owners (Pemilik Sewa Beli ) : N/A
Employer / Lessors (Majikan / Pemajak) : SST: 8.00% : RM 9.13
Stamp Duty : RM 10.00
Period of Coverage (a) From (Dari) : 30 JUN 2024 To (Hingga) : 29 JUN 2025 (DUTI SETEM)
(Tempoh Perlindungan)
Time : 01:28PM To Midnight : 11:59:59 pm
Total Contribution : RM 133.20
(b) Any subsequent period for which you shall pay and we shall (JUMLAH)
agree to accept a renewal contribution
Sebarang tempoh selanjutnya untuk mana anda membayar dan kami bersetuju
menerima caruman pembaharuan
The Motor Vehicle Any of the following (Mana - mana daripada yang berikut): Kenderaan Motor
Registration No. Make Type of Body Cubic Capacity Year of Seating Capacity Your Estimate of Value
Manufacture Including Driver Including Accessories
No. Pendaftaran Buatan Jenis Badan Keupayaan Enjin Tahun Diperbuat Muatan Tempat Duduk Nilai Anggaran Anda
termasuk Pemandu termasuk Aksesori
JPK8427 YAMAHA MOTORCYCLE 134 CC 2013 2 Third Party
135LC MY2013

Date of Signature of Proposal and Declaration Claims Excess : RM 0.00 Engine (Enjin) : G399EE116844
Tarikh Cadangan dan Perakuan Ditandatangan (Ekses Tuntutan)
Chassis (Casis) : PMYKG0540D0116844
Subject to the terms and conditions of the Certificate and endorsement as numbered below :
Tertakluk kepada peraturan - peraturan dan syarat - syarat Sijil dan pengendorsan seperti disenaraikan di bawah :
Named Driver : 1) ALL RIDERS
Include Endorsement No :3(p)
Additional Extra Coverage/Endorsements :-
Code Description Sum Covered Contribution
03 ALL RIDERS 0 50.70

LEGISLATION:-
Road Transport Act, 1987 (Malaysia) Motor Vehicles (Third Party Risks and Compensation) Act (Cap 189) Republic of Singapore Motor Vehicles (Third Party Risks and
Compensation) Rules (Republic of Singapore) Motor Vehicles Takaful (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam (the reference to legislation under the
heading "Avoidance of Certain Terms and Right of Recovery" is limited to Section 94, 95 and 96 of the Road Transport Act 1987 (Malaysia) Section 7, 8 and 9 of the Motor
Vehicles (Third Party Risks and Compensation) Act (Cap 189) Republic of Singapore and Section 7 of the Motor Vehicles Takaful (Third Party Risks) Act (Cap 90) Negara
Brunei Darussalam.
UNDANG - UNDANG:-
Akta Pengangkutan Jalan Raya, 1987 Malaysia, Akta Kenderaan Motor (Risiko Dan Pampasan Pihak Ketiga) (Cap 189) Republik Singapore, Peraturan Kenderaan Motor
(Risiko Dan Pampasan Pihak Ketiga) 1960 Republik Singapura, Akta Takaful Kenderaan Motor (Risiko Pihak Ketiga) (Cap 90) Negara Brunei Darussalam (rujukan kepada
undang - undang di bawah tajuk "Pengelakan Peraturan - Peraturan Dan Hak Tuntutan Tertentu" adalah terhad kepada Seksyen 94, 95 dan 96 Akta Pengangkutan Jalan Raya ,
1987 Malaysia. Seksyen 7, 8 dan 9 Akta Kenderaan Motor (Risiko Dan Pampasan Pihak Ketiga) (Cap 189) Republik Singapura, dan Seksyen 7 Akta Takaful Kenderaan Motor
(Risiko Pihak Ketiga) (Cap 90) Negara Brunei Darussalam).

The benefit(s) payable under eligible product is protected by PIDM up to limits. Please refer to PIDM’s TIPS Brochure or contact Zurich General Takaful Malaysia Berhad or
PIDM (visit www.pidm.gov.my).
Manfaat-manfaat yang dibayar di bawah produk yang layak adalah dilindungi oleh PIDM sehingga had perlindungan. Sila rujuk Brosur Sistem Perlindungan Manfaat Takaful dan
Insurans PIDM atau hubungi Zurich General Takaful Malaysia Berhad atau PIDM (layari www.pidm.gov.my).

Limits of Liability:-
Had Tanggungan: For and on behalf of / Untuk dan bagi pihak
Limit of the amount of the Company's Liability under Section 1-3 .......... RM50.00 ZURICH GENERAL TAKAFUL MALAYSIA
Had jumlah tanggungan Syarikat di bawah Seksyen 1-3 ..........
BERHAD
Limit of the amount of the Company's Liability under Section 11-1(a) .......... Unlimited
Had jumlah tanggungan Syarikat di bawah Seksyen 11-1(a) ..........
Limit of the amount of the Company's Liability under Section 11-1(b) .......... RM3,000,000.00
Had jumlah tanggungan Syarikat di bawah Seksyen 11-1(b) ..........

Limitation as to Use : As shown in the Certificate of Takaful

Had Penggunaan Seperti ditunjukkan dalam Sijil Takaful
:
Geographical Area : Malaysia, Republic of Singapore and Negara Brunei Darussalam Shamsul Azman
Had Wilayah : Malaysia, Republik Singapura dan Negara Brunei Darussalam
Chief Executive Officer
Authorised Driver : As shown in the Certificate of Takaful
Pemandu Yang Dibenarkan : Seperti ditunjukkan dalam Sijil Takaful

Page 1 of 3
 MOTORCYCLE FOR PRIVATE USE Code / Kod 18 MY3
CERTIFICATE OF TAKAFUL SIJIL TAKAFUL
ROAD TRANSPORT ACT, 1987 (MALAYSIA) AKTA PENGANGKUTAN JALAN RAYA, 1987 (MALAYSIA)
THE MOTOR VEHICLES (THIRD PARTY RISKS, RULES 1959 (MALAYSIA) PERATURAN KENDERAAN MOTOR (RISIKO PIHAK KETIGA) 1959 (MALAYSIA)
THE MOTOR VEHICLES (THIRD PARTY RISKS AND COMPENSATION) ACT AKTA KENDERAAN MOTOR (RISIKO DAN PAMPASAN PIHAK KETIGA) (CAP 189) (REPUBLIK SINGAPURA)
(CAP 189) (REPUBLIC OF SINGAPORE) PERATURAN KENDERAAN MOTOR (RISIKO DAN PAMPASAN PIHAK KETIGA) 1960 (REPUBLIK SINGAPURA),
THE MOTOR VEHICLES (THIRD PARTY RISKS AND COMPENSATION) RULES 1960 (REPUBLIC OF SINGAPORE) AKTA TAKAFUL KENDERAAN MOTOR (RISIKO PIHAK KETIGA) (CAP 90) NEGARA BRUNEI DARUSSALAM
THE MOTOR VEHICLES TAKAFUL (THIRD PARTY RISKS) ACT (CAP 90) NEGARA BRUNEI DARUSSALAM

Certificate No. (No. Sijil) : 222450185897-00 T67713K-000

1. Index Mark and Registration Number of Vehicle : JPK8427 NCD : 25.00 %

(Tanda Indeks dan Nombor Pendaftaran Kenderaan)
: YAMAHA 135LC MY2013 4 SPEED ROTARY
2. Name of Certificate Holder (Nama Pemegang Sijil) : KHAMIS BIN DOLE
3. Effective date of the Commencement of Covered for the purposes of the Regulations, Ordinance of Enactment : 30 JUN 2024
(Tarikh Perlindungan Mula Berkuatkuasa bagi tujuan Peraturan - Peraturan, Ordinan atau Enakmen)
4. Date of Expiry of the Takaful (Tarikh Perlindungan Tamat) : 29 JUN 2025
5. Persons or Classes of Persons entitled to drive* (Orang atau Kelas Orang yang berhak memandu*) :

a) Policyholder b) Any other person who is riding on the Policyholder's order or with his permission. Provided
that the person riding is permitted in accordance with the licensing or other laws or regulations to drive the
Motor Vehicle or has been so permitted and is not disqualified by order of a Court of Law or by reason of any
enactment or regulation in that behalf from riding the Motorcycle.

Limitation on Usage
Use for social domestic and pleasure purposes and by the Participant in person in connection with his business
or profession. The certificate does not cover :- Use for hire or reward, racing, pace-making, reliability
trial, speed- testing or the carriage of goods (other than samples) in connection with any trade or business
or use for any purpose in connection with the Motor Trade.

* Limitations rendered inoperative by Section 95 of the Road Transport Act 1987 (Malaysia) or Section 8 of the Motor Vehicles (Third Party Risks and Compensation) Act (Cap 189) Republic of
Singapore or Section 7 of the Motor Vehicles Takaful (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam are not to be included under these heading.

* Had - had yang tidak lagi berkuatkuasa kerana Seksyen 95 Akta Pengangkutan Jalan Raya, 1987 (Malaysia) atau Sekyen 8 Akta Kenderaan Motor (Risiko Dan Pampasan Pihak Ketiga) (Cap 189)
Republik Singapura atau Seksyen 7 Akta Takaful Kenderaan Motor (Risiko Pihak Ketiga) (Cap 90) Negara Brunei Darussalam tidak boleh dimasukkan di bawah tajuk ini.

Covered in pursuance to cover Note No : T67713K-24027887

Dikeluarkan mengikut Nota lindungan No :

I / We hereby certify that the Certificate of Takaful to which the Certificate is issued
For and on behalf of / Untuk dan bagi pihak
in accordance with the provisions of Part IV of the Road Transport Act, 1987
ZURICH GENERAL TAKAFUL MALAYSIA
(Malaysia), Motor Vehicles (Third Party Risks & Compensation) Act (Cap 189)
BERHAD
Republic of Singapore and the Motor Vehicles Takaful (Third Party Risks) Act (Cap
90) Negara Brunei Darussalam.

Saya / Kami dengan ini mengesahkan bahawa Sijil Takaful yang berkaitan
dengan Sijil ini dikeluarkan selaras dengan peruntukan - peruntukan Bahagian IV Shamsul Azman
Akta Pengankutan Jalan Raya, 1987 (Malaysia), Akta Kenderaan Motor (Risiko Dan Chief Executive Officer
Pampasan Pihak Ketiga) (Cap 189) Republik Singapura dan Akta Takaful
Kenderaan Motor (Risiko Pihak Ketiga) (Cap 90) Negara Brunei Darussalam

Page 2 of 3
CERTIFICATE OF TAKAFUL

This Certificate is not transferable to a new owner of the Vehicle .

If for any reason the Coverage is terminated during its currency this Certificate must be returned to the Takaful Operator or if this Certificate
has been lost or destroyed a Statutory Declaration to that Effect must be made . Failure to comply with this obligation is an offence under the
compulsory Takaful Legislation.
This Certificate must be returned if the Coverage is suspended during its currency.

SIJIL TAKAFUL

Sijil ini tidak boleh dipindahkan kepada pemilik baru Kenderaan.

Jika atas sebarang sebab Perlindungan Takaful ini ditamatkan semasa ia masih berkuatkuasa Sijil ini mesti dipulangkan kepada Pengendali
Takaful atau jika Sijil ini telah hilang atau dimusnahkan , satu Pengakuan Berkanun menyatakan demikian mesti dibuat. Kegagalan untuk
mematuhi kewajipan ini adalah satu kesalahan di bawah Undang - Undang Takaful wajib.
Sijil ini mesti dipulangkan jika Perlindungan digantung semasa ia masih berkuatkuasa.

IMPORTANT NOTICE
If you are involved in an accident causing injury to any person or damage to any property or other vehicle you must :
(a) Try to obtain names and address of any witness to the accident.
(b) Report to the Takaful Operator immediately.
(c) Refer to the Takaful Operator immediately all communications received from the Police Authorities.
(d) Send to the Takaful Operator immediately all letters from Third Parties unanswered.
(e) Not to pay money to any Party involved in the accident without the Takaful Operator's written permission.

NOTIS PENTING
Sekiranya anda terlibat di dalam sebarang kemalangan yang menyebabkan kecacatan kepada sesiapa atau kerosakan kepada
sebarang harta benda atau sebarang kereta anda mesti :
(a) Cuba mendapatkan saksi-saksi kepada kemalangan itu.
(b) Melaporkan kepada Pengendali Takaful dengan segera.
(c) Merujuk kepada Pengendali Takaful dengan segera segala perhubungan yang diterima daripada pihak berkuasa Polis.
(d) Mengirimkan kepada Pengendali Takaful dengan segera semua surat - surat yang diterima dari pihak - pihak lain tanpa
berjawab.
(e) Jangan membayar wang kepada sebarang pihak yang terlibat di dalam kemalangan itu tanpa mendapat kebenaran bertulis
dari Pengendali Takaful ini.

I / We hereby certify that the Certificate of Takaful to which the Certificate is issued For and on behalf of / Untuk dan bagi pihak
in accordance with the provisions of Part IV of the Road Transport Act, 1987 ZURICH GENERAL TAKAFUL MALAYSIA
(Malaysia), Motor Vehicles (Third Party Risks & Compensation) Act (Cap 189) BERHAD
Republic of Singapore and the Motor Vehicles Takaful (Third Party Risks) Act (Cap
90) Negara Brunei Darussalam.

Saya / Kami dengan ini mengesahkan bahawa Sijil Takaful yang berkaitan
dengan Sijil ini dikeluarkan selaras dengan peruntukan - peruntukan Bahagian IV Shamsul Azman
Akta Pengankutan Jalan Raya, 1987 (Malaysia), Akta Kenderaan Motor (Risiko Dan
Chief Executive Officer
Pampasan Pihak Ketiga) (Cap 189) Republik Singapura dan Akta Takaful
Kenderaan Motor (Risiko Pihak Ketiga) (Cap 90) Negara Brunei Darussalam

Page 3 of 3
 Participant's Copy

REG. NO. : W10-1808-31038416

NO : GI2422458863
DATE : 30 JUN 2024
CLIENT CODE :
ACCOUNT CODE : T67713K-000

KHAMIS BIN DOLE

T/L4 KAMPUNG PARIT LAHAK DARAT, MUKIM
6 TONGKANG PECHAH BATU, PAHAT JOHOR
83010 BATU PAHAT
JOHOR DARUL TAKZIM MALAYSIA
REG NO : 001838395392

CLASS : MOTORCYCLE FOR PRIVATE USE

TAKAFUL CONTRIBUTION

VEHICLE NO : JPK8427
VEHICLE BODY : MOTORCYCLE
SEATING CAPACITY : 2
CERTIFICATE NO : 222450185897-00
PERIOD OF TAKAFUL : 30 JUN 2024 TO 29 JUN 2025

Description Amount SST Rate SST Amount Total (RM)

Contribution 114.07 8.00 9.13 123.20
Total Before Disbursement 114.07 9.13 123.20
Stamp Duty (Disbursement) 10.00 0.00 10.00

Total After Disbursement 124.07 9.13 133.20

PT Voucher 0.00
Total Amount Payable 133.20

A Cashier’s Receipt will be given on payment of this account

E. & O.E.
THIS IS A COMPUTER GENERATED FORM AND DOES NOT REQUIRE A SIGNATURE Page 1 of 1