Important : Service Tax Revision
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© Zurich Malaysia
Alliance Bank is an authorized distributor of Zurich General Insurance Malaysia.
Step 1
Plan
Step 2
Details
Step 3
Payment
1
2
3
1. Effective Date
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2. Please select your preferred plan
Plan1
RM 172.18
Plan2
RM 280.18
Plan3
RM 604.18
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3. Insured Name (as per MyKad or Passport)
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4. Insured's MyKad or Passport No.
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5
. Date Of Birth
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6
. Gender
Male
Female
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7
. Your Mail
(Optional)
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8
. Handphone No
PLEASE SELECT
010
011
012
013
014
016
017
018
019
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9
. Mailling Address
Address Line 1
Address Line 2
Post Code
Town/City
State
PLEASE SELECT
BRUNEI
FOREIGN COUNTRY
JOHOR DARUL TAKZIM
KEDAH DARUL AMAN
KELANTAN DARUL NAIM
LABUAN
MELAKA
NEGERI SEMBILAN DARUL KHUSUS
PAHANG DARUL MAKMUR
PERAK DARUL RIDZUAN
PERLIS INDERA KAYANGAN
PULAU PINANG
PUTRAJAYA
SABAH
SARAWAK
SELANGOR DARUL EHSAN
SINGAPORE
STATE CODE (FOR AD-HOC USE ONLY)
TERENGGANU DARUL IMAN
THAILAND
WILAYAH PERSEKUTUAN
PLEASE SELECT
Country
AFGHANISTAN
ALBANIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTARTICA
ANTIGUA & BARBUDA
ARCTIC OCEAN
ARGENTINA
ARMENIA
ARUBIA
ASHMORE AND CARTIER ISLANDS
ATLANTIC OCEAN
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BAKER ISLAND
BANGLADESH
BARBADOS
BARCELONA ESPANA
BASSAS DA INDIA
BELARUS
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BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA AND HERZEGOVINA
BOTSWANA
BOUVET ISLAND
BRAZIL
BRITISH INDIAN OCEAN TERRITORY
BRITISH VIRGIN ISLANDS
BRUNEI
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
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COCOS (KEELING) ISLANDS
COLOMBIA
COMOROS
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CORAL SEA ISLANDS
COSTA RICA
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CUBA
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CZECH REPUBLIC
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DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
ECUADOR
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EL SAVADOR
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EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPHIA
EUROPA ISLAND
FALKLAND ISLANDS
FAROE ISLAND
FIJI
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FRANCE
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FRENCH POLYNESIA
FRENCH SOUTHERN & ANTARCTIC LANDS
GABON
GAMBIA
GAZA STRIP
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GERMANY
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GREAT BRITAIN
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HAITI
HCARD ISLAND & MCDONALD ISLANDS
HOLY SEE (VATICAN CITY)
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ICELAND
INDIA
INDIAN OCEAN
INDONESIA
IRAN
IRAQ
IRELAND
ISLE OF MAN
ISRAEL
ITALY
IVORY COAST
JAMAICA
JAN MAYEN
JAPAN
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JERSEY
JOHNSON ATOLL
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JUAN DE NOVA ISLAND
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LAOS
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MACAU
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MALTA
MAN ISLE
MARSHALL ISLANDS
MARTINIQUE
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MAURITIUS
MAYOTTE
MEXICO
MICRONESIA, FEDERATED STATES
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MONACO
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MOZAMBIQUE
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NAURU
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NEPAL
NETHERLANDS
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NICARAGUA
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NIGER
NIGERIA
NORFOLK ISLAND
NORTEHRN IRELAND
NORTH KOREA
NORTHERN MARIANA ISLANDS
NORWAY
OMAN
PACIFIC OCEAN
PAKISTAN
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PARACELL ISLANDS
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PERU
PHILIPPINES
PITCAIRN ISLANDS
POLAND
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QATAR
REUNION
ROMANIA
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RUSSIAN FEDERATION
RWANDA
SAINT KITTS AND NEVIS
SAINT LUCIA
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SAN MARINO
SAU TOME AND PRINCIPE
SAUDI ARABIA
SCOTLAND
SENEGAL
SERBIA AND MONTENEGRO
SEYCHELLES
SIERRA LEONE
SINGAPORE
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SOUTH GEORGIA & SOUTH SANDWICH ISLANDS
SPAIN
SPRATLY ISLANDS
SRI LANKA
ST HELENA
ST LUCIA
ST VINCENT & THE GRENADINES
SUDAN
SURINAME
SVALBARD
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SWEDEN
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SWITZERLAND
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THAILAND
TOGO
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TONGA
TRINIDAD AND TOBAGO
TROMELIN ISLAND
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TURKS & CAICOS ISLANDS
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UGANDA
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UNITED ARAB EMIRATES
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UZBEKISTAN
VANUATU
VENEZUELA
VIETNAM
VIRGIN ISLANDS
WAKE ISLAND
WALES
WALLS AND FUTUNA
WEST BANK
WESTERN SAHARA
WESTERN SAMOA
WORLD
WORLD WIDE
YANGON
YEMEN
ZAIRE
ZAMBIA
ZIMBABWE
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10
. Nominee (Optional)
Name as per MyKad/ Passport
MyKad or Passport No.
Date Of Birth
Relationship
PLEASE SELECT
AUNT
BROTHER
BROTHER IN LAW
COUSIN BROTHER
COUSIN SISTER
DAUGHTER
DAUGHTER IN LAW
EMPLOYEE AND CHILDREN
EMPLOYEE AND FAMILY
EMPLOYEE AND SPOUSE
EMPLOYEE ONLY
EMPLOYER
FAMILY
FATHER
FATHER IN LAW
FIANCEE
FRIEND
GRANDDAUGHTHER
GRANDFATHER
GRANDMOTHER
GRANDSON
UNCLE
HUSBAND
MORTGAGEE
MOTHER
MOTHER IN LAW
NEPHEW
NIECE
COUSIN
PARTNER
SELF
SISTER
SISTER IN LAW
SON
WIFE
SON IN LAW
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Effective From
Effective To
Promo Code
Do you have a promo code?
Total Payable Amount
Basic Premium
Stamp Duty
Commission
I hereby consent to the automatic renewal and automatic billing of this policy. I understand that automatic renewal of this policy is subject to terms and conditions of the policy contract, as well as the successful payment of the renewal premium.
Yes
No
You acknowledge that the purchase is done via Zurich Agent’s portal. An agent will earn commission, provide you seamless and personalised product/claim services.
You may purchase a similar product directly from Zurich General Insurance and it is commission-free. You will self-serve your insurance needs or
contact Zurich
for assistance.
Important
: Please read this
Product Disclosure Sheet
for more information about the product and take note for your
Duty of Disclosure
before proceeding. Alternatively, you may visit Zurich branches for your coverage needs.
DISCLAIMER
I / We hereby give my / our unconditional and unequivocal consent to you and all your related companies to process my / our personal data revealed hereto. You are at liberty to process the data and share the information thereto with any of your service providers and your other related companies provided that the revelation of my / our personal data strictly for the purposes in relation to the insurance which I / We have applied hereto. The consent given hereto is in line with the requirement set forth in the Personal Data Protection Act 2010.
I hereby consent to the processing of my personal data for marketing and promotional purpose within and outside Malaysia including sending me information on products, services, promotions or other events by you, your advisors/agents and group of companies, as well as relevant third parties, with whom Zurich General Insurance Malaysia Berhad maintains business referral or other arrangement. Note: The processing of your personal data is subject to Zurich General Insurance Malaysia Berhad's Personal Data Protection Notice, as publish on
Zurich Website
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Benefit
Benefit Description
Plan 1 (RM)
Plan 2 (RM)
Plan 3 (RM)
1.
Accidental Death
100,000
200,000
500,000
2.
Accidental Permanent Disablement
100,000
200,000
500,000
3.
Death due to Dengue Fever
100,000
200,000
500,000
4.
Double Indemnity on Public Conveyance
100,000
200,000
500,000
5.
Daily Hospital Income
200 per day
300 per day
400 per day
6.
ATM Withdrawal
1,000
1,500
2,000
7.
Debit and Credit Card Indemnity
500
1,000
1,500
8.
Saving Account Indemnity
500
1,000
1,500
9.
Renewal Bonus
50% on second year renewal
Terms of Use
Personal Data Protection Notice
Frequently Ask Question (FAQ)
Product Disclosure and Policy Wording
Click to view
PIDM's TIPS brochure
The benefit(s) payable under this product is (are) protected by PIDM up to limits. For more information, please refer to PIDM's Takaful and Insurance Benefits Protection System brochure on
Zurich General Insurance Malaysia's site
or
PIDM's website
.
© Zurich Malaysia