TO : _______________________________

FAX NUMBER : _________________

CANCELLATION/TRANSFER OWNERSHIP
Insured(Owner): __________________________________ Date : ___________________
Address : Current Address

Please amend address :

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Contact No: H/p : ____________________Office :_____________________Home : ____________________
Vehicle No : ___________________ Cover Note/Policy No : __________________
Period of Insurance : _______________________________

AXA Affin General Insurance Berhad (23820-W)

GROUND FLOOR WISMA BOUSTEAD
71 JALAN RAJA CHULAN 50200 KUALA LUMPUR
TEL : 03 2170 8282 FAX : 03 2031 7282 (Attn: Cara Cheah)

Dear Sirs/Madams,

With reference to the above, I shall be grateful if you could effect the following :

1. ( ) Cancel the above-numbered policy with effect from _______________________ as the car has been sold.

2. ( ) Transfer the rights and interest of the above policy to the new owner,
_______________________________________________________________________

In accordance with the Road Transport Act 1987, I return herewith the following document for your necessary attention:
(compulsory for 1 & 2 only )
Original Certificate of Insurance and Policy

OR
Statutory Declaration of lost of Certificate of Insurance

3. ( ) Withdraw my _________ % NCD from the above vehicle with effect from ______________________
for transfer to new vehicle. I shall pay for the recovery premium due.

Trust the above is in order.

Thank you.

Yours faithfully,

Signature of Insured(Owner)

Name : ___________________________________ New I/C No : ______________________________

Enc.
Under Motor Tariff, Section 2 (General Regulations) Sub-section 22A(ii), the original Certificate of Insurance must be returned for cancellation. If for any reason the Certificate cannot be
returned a Statutory Declaration must be obtained.
Any refund of premium may only be calculated as from the date of receipt of the Certificate or the Statutory Declaration.