Plan Sum Insured Per Student (RM) Bene ts P10 P20 P30 1 Accidental Death 15,000 20,000 30,000 2 Accidental Permanent Disablement 50,000 50,000 100,000 3 Accidental Death on Public Common Carrier* N/A 20,000 30,000 4 Accidental Death in School Premise* N/A 20,000 30,000 5 Compassionate Death Bene t 1,000 2,000 2,000 6 Bereavement for Death Due to Dengue 10,000 10,000 10,000 7 Kidnapping Extension N/A 20,000 30,000 8 Education Allowance N/A 20,000 25,000 9 Allowance for School / Tuition Fees N/A 200 400 10 Accidental Medical Expenses 2,000 3,000 4,000 11 Accidental Dental Bene t N/A 250 500 12 Hospital Cash Allowance** 50 100 100 13 Ambulance Fees** 100 150 250 14 Sinseh or Traditional Treatment N/A 250 250 15 Prosthesis / Wheelchair Bene t N/A 1,000 1,000 16 Travel Expenses** a) Government Hospital N/A 50 100 b) Private Hospital N/A 25 50 Annual Premium Per Student (RM) (Subject to 6% Service Tax and RM10 Stamp Duty. The applicability of stamp duty and any taxes are subject to prevailing laws of Malaysia.) 10 20 30 0UHKKP[PVU[V[OL(JJPKLU[HS+LH[O)LULÄ[ /VZWP[HSPZLKVYZLY]PJLZYLUKLYLKPU4HSH`ZPHVUS`
Plan P10 Plan P20 Plan P30 STUDENT PROTECTION PERSONAL ACCIDENT PROPOSAL FORM BORANG CADANGAN KEMALANGAN DIRI MURID Important Notice Please disclose fully all material facts. Whenever in doubt as to whether a fact is relevant or not, kindly refer to your intermediary or our servicing branch. Failure to disclose any material fact may result in refusal of claim or claim made by a third party against you. In such cases, you are personally liable for such claims. Notis Penting Sila dedahkan sepenuhnya semua fakta material. Apabila ragu-ragu sama ada sesuatu fakta itu relevan atau tidak, sila rujuk kepada pengantara anda atau cawangan servis kami. Kegagalan untuk mendedahkan sebarang fakta material boleh mengakibatkan penolakan tuntutan atau tuntutan yang dibuat oleh pihak ketiga terhadap anda. Dalam kes sedemikian, anda bertanggungjawab secara peribadi untuk tuntutan tersebut. PERSONAL DATA PROTECTION ACT 2010 A copy of the Privacy Notice will be sent to you together with your Insurance Policy upon acceptance of your Proposal by Us and can also be found at mpigenerali.com. AKTA PERLINDUNGAN DATA PERIBADI 2010 Sesalinan Notis Privasi akan dihantar bersama-sama dengan Polis Insurans anda setelah Cadangan anda diterima oleh Kami dan juga boleh didapati di mpigenerali.com. STUDENT PERSONAL PARTICULARS / BUTIR-BUTIR MURID / Name of Student / Nama Murid : ......................................................................................................................................................................................... Birth Cert No. / New IC No. / Passport No. / No.Surat Beranak / No. K.P. Baru / No. Pasport :……………………………………………………………….. Nationality / Kewarganegaraan …………………………………………………… Date of Birth / Tarikh Lahir : ............................................................................. Age / Umur: ……………………………………………………………… Gender / Jantina : Male / Lelaki Female / Perempuan Name Of Educaton Institution / Nama Institusi Pendidikan : ……………………………………………………………………………………………………….. PARENT’S / LEGAL GUARDIAN’S PARTICULARS / BUTIRAN IBUBAPA / PENJAGA SAH Name of Parent / Legal Guardian / Nama Ibu Bapa / Penjaga Sah : ….............................................................................................................................. Relationship to Student / Hubungan dengan Murid : ........................................... Nationality / Kewarganegaraan : ……………………………………. New IC No. / Passport No. / No. K.P.Baru / No. Pasport : .............................................................................. Occupation / Pekerjaan : ............................................................... Home Address / Alamat Rumah :......................................................................................................................................................................................... Postcode / Poskod : ………………………………………………………………….. Email / Emel : ………………………………………………………….. Mobile Phone No. / No. Telefon Bimbit : ............................................................ House Phone No: ........................................................................... I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above. Saya/Kami memahami bahawa ia adalah tugas saya/kami untuk memberikan perhatian yang munasabah untuk tidak membuat salah nyataan dalam menjawab soalan di dalam Borang Cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab soalan di atas dengan tepat dan sepenuhnya. I/We acknowledge that the essential information on the features of the product and my/our key obligations under the contract have been satisfactorily explained to me/us. Saya/Kami mengesahkan bahawa maklumat penting produk ini dan tanggungjawab utama saya/kami di bawah kontrak insurans ini telah dijelaskan dengan memuaskan kepada saya/kami. I/We would like to receive special offers, promotions, surveys and information related to the insurance products, events and services of MPI Generali Insurans Berhad. Saya /Kami ingin menerima tawaran istimewa, promosi, tinjauan dan maklumat berkaitan produk insurans, acara dan perkhidmatan MPI Generali Insurans Berhad. --------------------------------------------------------------------------------------- ------------------------------------------------------------- Signature of Parent / Legal Guardian / Tandatangan Ibu Bapa / Penjaga Sah Date /Tarikh DECLARATION BY AGENT/ PERAKUAN OLEH EJEN FOR OFFICE USE ONLY/ UNTUK KEGUNAAN PEJABAT SAHAJA I hereby declare that I have sighted the original NRIC / Birth Cert./ Passport and verified the identity of the applicant and beneficiary. Dengan ini saya mengaku bahawa saya telah melihat No K.P / Sijil Lahir / Pasport asal dan telah mengesahkan identiti pemohon dan benefisiari. Payment Date / Tarikh Bayaran : Agency/ Agent / Agensi/ Ejen: Agent Code / Kod Ejen: Person-In-Charge / Wakil yang Sah ………………………………………………… ………………………………………………… ………………………………………………… ………………………………………………… ……………………………. Agents Signature/ Tandatangan Ejen ……………………………………………….. Agent’s Name/ Nama Ejen
PRODUCT DISCLOSURE SHEET Read this Product Disclosure Sheet before you decide to take up the Student Protection PA Insurance. Be sure to also read the general terms and conditions. PA/05/2022 1 1. What is this product about? This is a yearly renewable product that provides coverage to students in the event of injuries, disability or death caused solely and directly by accidental means. 2. What are the covers/benefits provided? This product covers: Benefits Sum Insured Per Student (RM) P10 P20 P30 1. Accidental Death 15,000 20,000 30,000 2. Accidental Permanent Disablement 50,000 50,000 100,000 3. Accidental Death on Public Common Carrier* N/A 20,000 30,000 4. Accidental Death in School Premise* N/A 20,000 30,000 5. Compassionate Death Benefit 1,000 2,000 2,000 6. Bereavement for Death Due to Dengue 10,000 10,000 10,000 7. Kidnapping Extension N/A 20,000 30,000 8. Education Allowance N/A 20,000 25,000 9. Allowance for School / Tuition Fees N/A 200 400 10. Accidental Medical Expenses 2,000 3,000 4,000 11. Accidental Dental Benefit N/A 250 500 12. Hospital Cash Allowance** 50 100 100 13. Ambulance Fees** 100 150 250 14. Sinseh or Traditional Treatment N/A 250 250 15. Prosthesis / Wheelchair Benefit N/A 1,000 1,000 16. Travel Expenses** a) Government Hospital N/A 50 100 b) Private Hospital N/A 25 50 Annual Premium/ Premium Tahunan RM10.00 RM20.00 RM30.00 *in addition to the Accidental Death Benefit **hospitalised or services rendered in Malaysia only • Note: Please refer to the Table of Compensation for accidental death and permanent disablement in the policy contract. • Duration of cover is for one (1) year. You need to renew your insurance cover annually. STUDENT PROTECTION PA RM21.20
PRODUCT DISCLOSURE SHEET Read this Product Disclosure Sheet before you decide to take up the Student Protection PA Insurance. Be sure to also read the general terms and conditions. PA/05/2022 2 3. How much premium do I have to pay? The total premium that you have to pay will vary depending on the plan selected and our underwriting requirements. Note: • Premium rates are not guaranteed, and revision, if any, shall reflect the Company’s claims experience, and any other justified circumstances. The Company shall notify you of any premium revision by giving you at least thirty (30) days’ advance notification before the policy expiry. • Annual premiums must be paid yearly for continued protection. Schedule of Premium P10 (RM) P20 (RM) P30 (RM) Annual Premium Per Person 10.00 20.00 30.00 4. What are the fees and charges I have to pay? In addition to the premium, you have to pay: Amount a. Service Tax 6% of gross premium b. Stamp duty RM 10.00 The premium that you have to pay includes the commission paid to the intermediaries, if any, amounting to 25% of the premium. The applicability of stamp duty and any taxes are subject to prevailing laws of Malaysia. 5. What are some of the key terms and conditions that I should be aware of? • Importance of disclosure: Non-consumer Insurance Contract Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for purposes related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant. Consumer Insurance Contract Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for yourself/family/dependants, you have a duty to take reasonable care not to make a misrepresentation in answering the questions in the Proposal Form (or when you apply for this insurance). You must answer the questions fully and accurately. Failure to take reasonable care in answering the questions may result in a voidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in the Proposal Form (or when you apply for this insurance), you are required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in the Proposal Form (or when you applied for this insurance) is inaccurate or has changed. You must observe and fulfil the Terms, Conditions, Endorsements, Clauses or Warranties of the Policy.
PRODUCT DISCLOSURE SHEET Read this Product Disclosure Sheet before you decide to take up the Student Protection PA Insurance. Be sure to also read the general terms and conditions. PA/05/2022 3 • Cooling-off Period You may cancel your policy by returning the policy within fifteen (15) days from the date of delivery of the policy. You are entitled to the return of the full premium paid less deduction of any claims or expenses incurred by Us in the issuance of the Policy, provided no claims have been made. • Premium Warranty Premium must be paid and received by us within sixty (60) days from the inception date of the cover, otherwise the cover is automatically cancelled and you will still be responsible to pay the proportion of premium for the period We have been on risk. • Age Limit The student must be between the age of three (3) years and twenty-one (21) years at the time of application. • Government Tax You agree to pay us for any taxes or charges imposed by the government in respect of the execution and delivery of this policy. • Claims Notification of claim must be made to Us in writing not later than thirty (30) days. You must submit your claim with all the supporting information and documents to us and give full cooperation to us in accessing your claim. Note: The above list is non-exhaustive. Please refer to the policy contract for the terms and conditions under this policy. 6. What are the major exclusions under this policy? This Policy does not cover death or any injury / disablement directly or indirectly caused by or in connection with any of the following: • insanity, committing or attempting to commit suicide (whether sane or insane), intentional self -inflicted injuries or any attempt thereat; • any form of sickness, illness, disease, infection or parasites and/or Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or Human Immunodeficiency Virus Infection (HIV). • congenital defect, pre-existing physical or mental defect or infirmity. • provoked murder or assault, wilful exposure to needless peril except in an attempt to save human life. • while travelling in an aircraft as a member of the crew, except only as a fare-paying passenger in an aircraft licensed for passenger service. • while participating in unlawful activities or committing or attempting to commit any unlawful act. • while participating in any professional sports. • martial arts or boxing, aerial activities including parachuting and hang-gliding, underwater activities exceeding fifty (50) meters in depth, mountaineering involving the use of ropes or mechanical guides. • racing (other than on foot), pace-making, speed or reliability trials. • driving or riding without a valid driving license. This will not apply if the Insured Person have an expired license but are not disqualified from holding or obtaining such driving license under any existing laws, by-laws and regulations. • being under the influence of drugs except prescribed by a legally licensed Medical Practitioner (but not for the treatment of drug addiction). • war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, military or usurped power, mutiny, popular uprising. • connection with: (a) ionising radiations or contamination by radioactivity from any nuclear fuel or from any nuclear waste from combustion of nuclear fuel. Solely for the purpose of this exclusion, combustion shall include any self-sustaining process of nuclear fission. (b) nuclear weapons material. NOTE: This above list is non-exhaustive. Please refer to the policy contract for the terms and exclusions for this policy.
PRODUCT DISCLOSURE SHEET Read this Product Disclosure Sheet before you decide to take up the Student Protection PA Insurance. Be sure to also read the general terms and conditions. PA/05/2022 4 7. Can I cancel my policy? You may cancel your policy at any time by giving written notice to us provided that no claims have been made during the current policy year. Upon cancellation, any refund of the premium will be based on the conditions stipulated in the policy contract. 8. What do I need to do if there are changes to my contact details? It is important that you inform us of any change in your contact details to ensure that all correspondences reach you in a timely manner. 9. Where can I get further information? Should you require additional information about personal accident insurance, please refer to the insuranceinfo booklet on ‘Personal Accident Insurance’, available at all our branches or you can obtain a copy from your insurance agent or visit www.insuranceinfo.com.my If you have any enquiries about this insurance or any other types of Personal Accident insurance products, you can contact us or your insurance intermediary or visit our website at www.mpigenerali.com MPI Generali Insurans Berhad (Reg No: 197301001061 (14730-X)) (Licensed under Financial Services Act 2013 and regulated by Bank Negara Malaysia) 8th Floor, Menara Multi-Purpose Capital Square 8, Jalan Munshi Abdullah 50100 Kuala Lumpur Tel: +603 2034 9888 Fax: +603 2694 5758 Email: [email protected] 10. Other types of Personal Accident cover available • The Gladiator Enhanced • Multi Lucky PA • Multi PA Protector IMPORTANT NOTE: YOU ARE ADVISED TO NOTE THE SCALE OF BENEFITS FOR DEATH AND DISABLEMENT IN YOUR INSURANCE POLICY. YOU MUST NOMINATE A NOMINEE AND ENSURE THAT YOUR NOMINEE IS AWARE OF THE PERSONAL ACCIDENT POLICY THAT YOU HAVE PURCHASED. YOU SHOULD READ AND UNDERSTAND THE INSURANCE POLICY AND DISCUSS WITH THE AGENT OR CONTACT THE INSURANCE COMPANY DIRECTLY FOR MORE INFORMATION. The information provided in this Product Disclosure Sheet is valid as at 18/05/2022