FOREIGN WORKER INSURANCE GUARANTEE

Date : 04-10-2020
JABATAN IMIGRESEN NEGERI KEDAH
KETUA PENGARAH IMIGRESEN
BAHAGIAN PEKERJA ASING
TINGKAT 1amp2
BANGUNAN KEMENTERIAN DALAM NEGERI (KDN)
PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN
BANDAR MUADZAM SHAH
06550 ALOR STAR

Dear Sir(s),

INSURANCE GUARANTEE NO : EGF-0159303 FOR RM500.00 EXPIRING 09-06-2022

As requested by PEMBINAAN ETIKA MURNI of 25 TAMAN DERGA JAYA, JALAN DATUK KUMBAR, -. We,
AmGeneral Insurance Berhad hereby guarantee and agree to pay on your written demand up to the maximum
aggregate sum of RM500.00 (RINGGIT MALAYSIA: FIVE HUNDRED ONLY), being the amount of security deposit
required to be deposited with you for 1 foreign worker(s) (as per list attached) employed by the said PEMBINAAN
ETIKA MURNI being surety for the repatriation expenses in the event that any one of them be repatriated in their course
of stay in Malaysia as employees of PEMBINAAN ETIKA MURNI.

This Guarantee is effective from 10-12-2020 until: 09-06-2022 within the limit of the aforesaid.

Notwithstanding the above, any claim arising hereunder must reach us in writing latest by 09-06-2022 and our liability to
pay any claim under this Guarantee shall expire on the said date notwithstanding the fact that this Guarantee may not
be returned to us for cancellation.

Yours faithfully,

For AmGeneral Insurance Berhad

Simon Anthony Herbert Elaine Kok Yoke Foong

Senior Vice President Head of Personal Lines
Product, Pricing & Insurance
Underwriting Product, Pricing &
Underwriting

Page 1
 EMPLOYEES PARTICULARS LISTING

INSURED NAME : PEMBINAAN ETIKA MURNI

BUSSINESS ADDRESS : 25 TAMAN DERGA JAYA, JALAN DATUK KUMBAR, -

INSURANCE GUARANTEE NO : EGF-0159303

NO. NAME SEX PASSPORT NO. NATIONALITY

REPON M BQ0648751 BANGLADESH

1

SUMMARY :

NATIONALITY NO. OF WORKERS IG AMOUNT PER WORKER (RM) TOTAL IG AMOUNT (RM)

BANGLADESH 1 500.00 500.00

GRAND TOTAL RM 500.00

Page 2
 STAMP DUTY PAID
UW·NMF149(E)

MYT-10-20-00470440

FOREIGN WORKERS INSURANCE GUARANTEE SCHEDULE

JADUAL GERENTI INSURANS PEKERJA ASING

Name and Address of Insured/ Nama dan Alamat Pihak Diinsuranskan e-Policy No. EGF-0159303
No.e-Polisi
PEMBINAAN ETIKA MURNI, 25 TAMAN DERGA JAYA, JALAN DATUK KUMBAR, -

Agent Code & Name R45700-00 & SUTERA

Kod & Nama Ejen INDERA JAYA SDN BHD

Postcode /Poskod: Gross Premium RM 50.00

5300 Premium Kasar

Business or Occupation Business Reg. No/New/Old NRIC No. Stamp Hasil RM 10.00
Perniagaan atau Pekerjiaan No Pendaftaran Syarikat/No KP Baru /lama Setem Hasil
AS0243122-H
CONSTRUCTION 6% Service Tax RM 3.00
6% Cukai Perkhidmatan
Total Payable RM 63.00
Period of Insurance / Tempoh Insurans Jumlah Berbayar

(a) From 10-12-2020 to 09-06-2022 (both dates inclusive)

Dari sehingga (termasuk kedua-dua tarikh)

(b) Any subsequent period for which the Insured shall pay and the Company shall Total Payable(OTC) RM 63.00
agree to accept a renewal premium Jumlah Berbayar di
Pada setiap tempoh yang berikutnya di mana Pihak Diinsuranskan sepatutnya Kaunter
membuat bayaran dan Syarikat kemudiannya bersetuju menerima premium
pembaharuan
DESCRIPTION OF INSURED PERSON(S) /DESKRIPSI PIHAK DIINSURANSKAN
On the following employee(s) of the Insured for which the Insured is responsible:
Ke atas pekerja-pekerja yang Diinsuranskan yang telah dipertanggungjawabkan ke atas Pihak Diinsuranskan:
IDCard No Name Of Worker/Sex Occp Sector Date Of Birth Passport No. Country Of Origin Work Permit Expiry
No Kad ID Nama Pekerja/Jantina Code/KodSektor Tarikh Lahir No.Passport Negara Asal Date
Pekerjaan Tarikh Tamat
Tempoh Permit
1 REPON(M) CONSTRUCTION 03-06-1983 BQ0648751 BANGLADESH 09-12-2021
Subject to the following Clauses /Warranties / Endorsements attached hereto:
Tertakluk kepada Fasal/Waranti/ Endorsemen berikut yang disertakan bersama ini:

Code / Kod Description /Deskripsi

ETC EXCLUSION OF TERRORISM COVER

Replacing Cover Note No. Issued By

Gantian No. Nota Perlindungan / Dikeluarkan Oleh

SUTERA INDERA JAYA SDN BHD
Previous Policy No.

No. Polisi Terdahulu

Date of Proposal or 04-10-2020

DeclarationTarikh Cadangan atau

Pengisytiharan

Date of Issue / Time 04-10-2020

Tarikh Dikeluarkan / Waktu

 FOREIGN WORKERS INSURANCE GUARANTEE SCHEDULE
JADUAL GERENTI INSURANS PERKERJA ASING
Attaching to and forming part of e-Policy No.: / Yang disertakan adalah sebahagian daripada No. e-Polisi : EGF-0159303

IMPORTANT NOTICE / NOTIS PENTING

1. The Insured shall read this Policy carefully, and if any error or misdescription be found herein, or if the cover is not in accordance with the wishes of the Insured,
advice should at once be given to the Company and the Policy returned for alteration.
Pihak Diinsuranskan hendaklah membaca Polisi ini dengan teliti, dan jika terdapat kesilapan atau keterangan yang salah, atau jika nota perlindungan tidak
memenuhi kehendak Pihak Diinsuranskan, Pihak Diinsuranskan hendaklah memberitahu kepada Syarikat dan mengembalikan Polisi untuk membuat pembetulan
sewajarnya.
2. Duty of Disclosure - STATEMENT PURSUANT TO FINANCIAL SERVICES ACT 2013, Section 129 Schedule 9, Para 5: It is the duty of the customer to take
reasonable care not to make a misrepresentation to the licensed insurer when answering any question which the insurer may request that are relevant to the
decision of the insurer whether to accept the risk or not and the rates and terms to be applied.
KEWAJIPAN PENDEDAHAN - Menurut Akta Perkhidmatan Kewangan 2013, Seksyen 129, Jadual 9, Perenggan 5: Adalah menjadi kewajipan pengguna untuk
mengambil penjagaan munasabah untuk tidak membuat salah nyataan kepada penanggung insurans berlesen semasa menjawab apa-apa soalan yang
diperlukan yang berkaitan dengan keputusan penanggung insurans samada untuk menerima atau tidak risiko dan kadar dan terma yang hendak dipakai.
3. Any changes in the information given must be reported to the Company immediately otherwise the Company may resume the right to decline all liability.
Sebarang pertukaran informasi diberi mesti dilaporkan kepada Syarikat serta merta, jika tidak Syarikat berhak menolak sebarang liabiliti.
4. In the event of any occurrence which might give rise to a claim, notice should be given immediately to the nearest Branch Office or your Servicing Agent followed
by such further steps, as are required by the Conditions of the Policy.
Jika berlaku apa-apa kejadian di mana suatu tuntutan boleh dibuat, notis hendaklah diberikan dengan serta merta kepada pejabat cawangan yang berdekatan
atau agen perkhidmatan diikuti dengan langkah-langkah yang diperlukan seperti tercatat di dalam Syarat-Syarat Polisi.
5. Insured who is not satisfied with the course of the action or decision of the Company, may seek redress or assistance with the Ombudsman for Financial Services
(OFS) or alternatively to approach Bank Negara Malaysia's Laman Informasi Nasihat dan Khidmat (LINK), addressed below:
Pihak Yang Diinsuranskan yang tidak berpuas hati dengan segala tindakan atau keputusan Syarikat boleh mendapatkan pembelaan atau bantuan daripada
Ombudsman Perkhidmatan Kewangan (OFS) atau melayari Laman Informasi Nasihat dan Khidmat (LINK), Bank Negara Malaysia yang beralamat seperti
dibawah:
a. Ombudsman Perkhidmatan Kewangan (OFS) b. Laman Informasi Nasihat dan Khidmat (LINK)
Tingkat 14, Blok Utama Tingkat Bawah, Blok C
Menara Takaful Malaysia Bank Negara Malaysia
No. 4, Jalan Sultan Sulaiman Peti Surat 10922
50000 Kuala Lumpur 50929 Kuala Lumpur

Tel : 03 2272 2811 Tel: 1300 88 5465

Fax : 03 2272 1577 Fax: 03 - 2174 1515

The following endorsements, warranties, clauses or extensions are not applicable unless indicated in the Policy Schedule, in which case the endorsement(s), warranty(ies),
clause(s) or extension(s) so indicated shall be deemed to form part of the policy
Endorsemen, waranti, fasal atau tambahan adalah tidak digunapakai kecuali dinyatakan di dalam Jadual Polisi di mana endorsemen waranti fasal atau tambahan yang
dinyata akan dianggap membentuk sebahagian daripada polisi

Code / Kod Description / Deskripsi

ETC EXCLUSION OF TERRORISM COVER
This insurance does not cover any loss or damage occasioned by or through or in consequence, directly or indirectly, of any act of terrorism.

For this purpose, an act of terrorism means an act including but not limited to the use of force or violence and /or the treat thereof, of any
person or group (s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), committed for
political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public or any section
of the public in fear.

Page 2 0820
INSURED NAME : PEMBINAAN ETIKA MURNI

COVER NOTE NO. : EGF-0159303

PRIVACY CLAUSE

1.0 PRIVACY CLAUSE

1.1 You hereby irrevocably consent, represent, authorise and confirm to AmGeneral that you have duly obtained the consent of
your directors, shareholders, authorised signatories, and employees or such other persons who are insured under the
Insurance Policy (collectively 'Third Parties'), for AmGeneral to:
a. provide the information required by AmGeneral for use in accordance with this Insurance Policy; and
b. provide the said directors, shareholders, authorised signatories, officers, employees, and other persons with information
on AmGeneral's products, services and/or offers (inclusive of the products, services and offers of the other entities
within the AmBank Group) which may be of interest and/or financial benefit to them,
at AmGeneral's sole discretion, without further reference to you.
1.2 You agree to undertake the responsibility to update AmGeneral in writing should there be any change to the personal and
financial information relating to the Third Parties.
1.3 AmGeneral reserves the right to amend this Section from time to time at AmGeneral's sole discretion by providing notice to
you.
1.4 In the event you have any enquiries or complaints concerning this Privacy Clause or the Third Parties wish to communicate
their change in marketing preference, you or the Third Parties may contact AmGeneral as per below details or you may
contact AmGeneral's nearest branch to you:

Customer Service Executive, Customer Contact Centre

Telephone No E-Mail
AmAssurance 1800-88-6333 customercare@amassurance.com.my
Kurnia Insurans 1800-88-3833 customercare@kurnia.com
 Invoice
Invois

Invoice No : MYT-10-20-00470440 Date : 04-Oct-2020

No. Invois Tarikh

Name : PEMBINAAN ETIKA MURNI

Nama

Insurer Address : 25 TAMAN DERGA JAYA,

Alamat JALAN DATUK KUMBAR,
-
ALOR SETAR,
5300 KEDAH

Agent Name : SUTERA INDERA JAYA Account No : R45700-00

Nama Agent SDN BHD No Akaun

Policy / Endorsement No : EGF-0159303

No. Polisi / Endorsemen

Class of Policy : FOREIGN WORKER INSURANCE GUARANTEE

Jenis Insurans GERENTI INSURANS PEKERJA ASING

Period of Insurance : From 10-12-2020 To 09-06-2022

Tempoh Insurans

No Description Total(RM)
1 Gross Premium / Premium Kasar 50.00
2 Rebate / Rebat 0.00
3 Service Tax / Cukai Perkhidmatan 6% 3.00
4 Stamp Duty / Duti Setem 10.00
5 Total Payable (OTC) / Jumlah Berbayar Di Kaunter 63.00
6 Total Payable / Jumlah Berbayar 63.00
AmGeneral Insurance Berhad

This is a computer generated document and it does not require a signature. This document shall not be invallidated solely on the
ground that it is not signed.
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