FAX TO : _________________________

FAX NUMBER : __________________

ADD NAMED DRIVER

Insured(Owner): __________________________________ Date : ___________________

Contact No: H/p : ____________________Office :_____________________Home : ____________________
Vehicle No : ___________________ Cover Note/Policy No : __________________
Period of Insurance : _______________________________
* Please refer ENDORSEMENT NO. M02F – Compulsory Excess
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AXA AFFIN ASSURANCE BERHAD (23820-W)
GROUND FLOOR WISMA GOLDHILL
67 JALAN RAJA CHULAN 50200 KUALA LUMPUR
TEL : 03 2170 8282 FAX : 03 2031 7282

Dear Sirs/Madams,

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

Add Named Driver :

1. Name : ___________________________________________________
New I.C : ___________________________________________________
RM10.00 chargeable per additional name
- after named driver no. 1 (the insured) & no. 2 (2nd additional named driver)

2. Name : ___________________________________________________
New I.C : ___________________________________________________
3. Name : ___________________________________________________
New I.C : ___________________________________________________
4. Name : ___________________________________________________
New I.C : ___________________________________________________

Trust the above is in order.

Thank you.
Yours faithfully,

----------------------------------------------------------------- Signature of Insured(Owner)

Name : ___________________________________New I/C No : ______________________________

* ENDORSEMENT NO. M02F – Compulsory Excess
In the event of any Loss or Damage to your vehicle, you are responsible in respect of each and every event for an
excess of RM400.00 in addition to the Excess stated in the Schedule if your vehicle is being driven by the following
persons authorised by you :
a. Person under the Age of 21 years
b. Person who is the holder of a Provisional (P) driving licence
c. Person who is the holder of a full driving licence of less then 2 years
d. Any person not named in the Schedule
e. Person named in the Schedule who is less then the Age of 21 years and/or the holder of a Provisional (P) driving
license and/or the holder of a Full driving licence of less than 2 years