ZURICH_Cancellation_Form_No_Signature

Section A: Details of Policyholder
Policyholder's Name:

First NameLast Name
NRIC/Buss Reg No./Passport:
Contact No. & Email:
Policy No. / Cover Note No. : (Delete where appropriate)
Vehicle No. :
Period of Cover:
to
Section B: Amendment of Policyholder or Vehicle Details
Policyholder's Name

First NameLast Name
Year of Make
Vehicle No.
Others (Please specify)
Engine/Chassis No.
CC/Tonnage
Section C: Instruction and Attention Please tick (V) where appropriate
Cancel abovementioned Policy/ Cover Note with effect from
(Note: JPJ Road Tax Cancellation Slip Policy or completed transfer of ownership must be enclosed with policy cancellation instruction)
Transfer NCD entitlement to Vehicle No
(Note: JPJ Road Tax Cancellation Slip Policy or completed transfer of ownership must be enclosed with policy cancellation instruction)
Withdraw NCD entitlement with effect from
Extend the period of insurance to
(For Motorcycle only) Transfer of policy to
Others (Please specify)
Section D: Refund and Authorisation
Refund of premium will be done electronically via e-payment. Please ensure that the account is active and belongs to the Policyholder.
Bank Name
Account No.
Section E: Additional Documentations Enclosed
Section F: Declaration
I/ We hereby undertake to indemnify and keep Zurich General Insurance Malaysia Berhad and its agents indemnified from all demands, suits and claims hereinafter initiated by any party(s) made under the endorsement/ cancelled cover note requested hereto by me / us.
Signature of Policyholder / Company's Stamp
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Section A: Details of Policyholder

Section B: Amendment of Policyholder or Vehicle Details

Section C: Instruction and Attention Please tick (V) where appropriate

Section D: Refund and Authorisation

Section E: Additional Documentations Enclosed

Section F: Declaration