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    Motor Accident Loss Claim Form & Checklist

    Uploaded by

    Adam Radin
    This form is required for loss claim with RHB Insurance.

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd

    Motor Accident Loss Claim Form & Checklist

    Uploaded by

    Adam Radin
    69 views4 pages
    This form is required for loss claim with RHB Insurance.

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

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    This form is required for loss claim with RHB Insurance.

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    69 views4 pages

    Motor Accident Loss Claim Form & Checklist

    Uploaded by

    Adam Radin
    This form is required for loss claim with RHB Insurance.

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
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    Serial No. : Motor/ RHB INSURANCE BERHAD o. no. 38000-u) LEVEL 6, TOWER ONE, RHB CENTRE, JALAN TUN RAZAK, 50400 KUALA LUMPUR TEL: 03-9281 2781 FAX (Claims): 03-8281 2729 (Pause 403) MOTOR ACCIDENT OR LOSS REPORT FORM ‘The Issue ofthis form isnot admission of lisbilty on the part of the Compary. Completion ltyour report refers toan ACCIDENT your report rotors, ‘to THEFT MaLovo11299 ADVICE TO POLICYHOLDERS Ploase sive a full answer to every question. Dashes are not sufficient and may cause delay. Quote your Policy Number on every communication unti a elaim reference is notified Pease complete the whole of this form. You are reminded that the Policy conditions require that every letter, wt, summons and process must be notified or forwarded to the Company immediately oh receipt, You must also tell us of any impending prosecution, inquest or fatal injury. DO NOT attempt to deal with ‘any Third Party claim yourself or make any offer or payment or admission of ibilly. If your policy covers ‘accidental damage to your vehicle, it may speed up authorisation of repair work if you obtain and forvard the repair estimates. Where an excess applies and repairs are authorisod by Company, the ropairer will be instructed to collect the amount of the excess direct from the Policyholder. Where the Policyholder incurs ‘expenses not covered by his policy (eg, Policy excoss or hiro of alternative traneport) he should pureue rocovery from any party belioved to be responsible, as the Compary is not lable to pay these expences, Pioase compte tho whole of this form with the exception of sections 3, 4 and 8, The Company normally defers settlement for stolen vehicles until Police have had time to complate their enguties. A great ‘number of stolen vehicles are recovered within a few weeks of the theft. Please follow up closely With the Police. Please answer all questions fully and retum this form without delay to ‘SECTION 1 - PARTICULARS OF INSURED OR POLICYHOLDER Policy No Vehicle Registration Covage: _ Gonpntwnive [-] Third Paty Fee athe L_] Name VG No. (New / Og) ‘Accress Telephone WiPhane No. ‘Occupation ‘Name and adress of Finance Co. interest SECTION 2 - PARTICULARS OF ACCIDENT / THEFT Dato of Accident / Theft Tine: AM TPM Dato of reporting to Insurer Pleas iicato typo of weather and Eght at time of accident: OC Fire Weather [raining TO awnsy Exact place of Rocident / Theft Full description of Accident /Thett Pariculars of Damage ‘Show area of impact by arrow and extent of damage by crosses on the diagram. Ts vehicle tin use: ve O tna, whore the vehicle ying naw we OI Pole Noted: ve no Date Police report lodged Namo of lnestigating Officer ve ‘Summon lesued wo O Station police repon lodged Police Report No, ‘SECTION 3 - PARTICULARS OF THIRD PARTY AND THIRD PARTY'S PROPERTY Name VENo, (New / O16) ‘Address | Telephone No. Registration No Make / Model | Parioulars of Damage ‘Show area of impact by arrow and extent of ‘damage by crosses on the diagram. MALc2I011299 SECTION 4 - PARTICULARS OF INJURED AND INJURIES Please incicate name(s) of inured person(s) and also any visible injures {state whethor driver oF passenger and in which vehicles or pedostian ) 8) Name Injuries dares ©) Name injuries Addcross ©) Name injuries Adress Name of Hospital / Clinic attending to injured persons): SECTION 5 - PARTICULARS OF DRIVER AND DRIVER'S LICENCE Name ‘Occupation hoe cence No WG No. (ew 7 Or) Paso nccate ype oficerce? Fut L] Provisional] intenatonal L] Please indicate group of vnicies to which ence applies Current Licence Period From To SECTION 6 - SKETCH PLAN OF ACCIDENT ‘Show postion of vehicles and person lnvoNio ndlcate rection of travel with anows. Give apprexmate measurements and show ralative importance of road signs, traffic ght o pedestrian crossing, MALC3/011290

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