Borang Tuntutan Kecurian Kenderaan Bermotor
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1 Borang Tuntutan Kecurian Kenderaan Bermotor Nota Penting: ANDA DIMINTA UNTUK MELENGKAPKAN BORANG INI DENGAN PENUH DAN MENGEMBALIKANNYA KEPADA PENGENDALI TAKAFUL DALAM TEMPOH TUJUH (7) HARI SELEPAS KECURIAN. SILA KEMUKAKAN JUGA SALINAN FOTOSTAT YANG BERIKUT : KAD PENDAFTARAN BORANG PENDAFTARAN PERNIAGAAN KAD PENGENALAN LAPORAN POLIS LESEN MEMANDU Pihak Pengendali Takaful tidak menanggung liabiliti atas pengeluaran borang ini. 1. PESERTA a. Nama Encik/Puan/Cik b. No. Kad Pengenalan atau No. Pendaftaran Perniagaan c. Alamat (Kediaman) Poskod No. Tel d. Alamat Perniagaan & Nama Syarikat Alamat Poskod No. Tel e. Jenis Perniagaan f. Milik Sendiri/Digaji oleh di selama tahun/bulan No. Tel Jenis Perdagangan Gaji bulanan RM termasuk elaun bulanan RM termasuk pendapatan lain g. Nota Lindung No. Sijil h. Parti Ketiga Komprehensif Sekiranya terdapat kekeliruan, kekaburan dan konflik adalam pentafsiran mana-mana terma atau syarat, versi Bahasa Inggeris adalah terpakai dan mengatasi versi Bahasa Malaysia. TP47/1/G CF-GCS-003
2 2. KENDERAAN Buatan & Jenis Warna Muatan Tempat Duduk atau Tan Tahun Dikeluarkan Harga dibayar semasa Belian Baru atau Terpakai semasa Belian No Pendaftaran No. Enjin No. Casis No. Buku Log Kenderaan Minyak Diesel atau Petrol a. Adakah kenderaan tersebut milik anda? b. Tarikh kenderaan dibeli c. Dibeli daripada di d. Diperkenalkan oleh Jurujual di e. Jika tertakluk kepada Perjanjian Sewa Bell berikan nama syarikat pinjarnan Sewa Beli Salinan fotostat Perjanjian Sewa Beli dilampirkan f. Berapa kali ansuran yang telah dibayar ketika kecurian? Ya Tidak g. Tarikh terakhir bayaran ansuran h. Takaful dibeli daripada dari menerusi di i. Bagi tujuan apakah kenderaan itu digunakan pada masa kecurian j. Adakah ia digunakan dengan pengetahuan dan kebenaran anda? k. Jika is sebuah motosikal (a) adakah terdapat gerabak kecil dibawa bersama? (b) adakah ya membawa pembonceng? l. Jika sebuah lori (a) adakah trailer dibawa bersama? (b) adakah mengangkut barangan? Jenis barangan? m. Apakah jenis lesen Permit Haulage (Persekutuan) yang dimiliki oleh kenderaan? Ya Tidak n. Berapa banyakkah kemalangan atau kerugian yang timbul sejak TIGA TAHUN yang lalu berkaitan dengan kenderaan ini atau lain-lain Kenderaan Bermotor yang dimiliki atau dipandu oleh anda atau orang lain? Jumlah Kenderaan yang dimiliki oleh Peserta Jumlah Kemalangan atau tuntutan Jumlah dibayar Kerosakan akibat Kemalangan Pihak Ketiga/ lain-lain Tuntutan Anggaran kos tuntutan yang tertunggak Nama Syarikat Insurans/Takaful 1 tahun lepas 2 tahun lepas 3 tahun lepas
3 3. PEMILIKAN KENDERAAN a. Semasa kecurian, siapakah yang menggunakan kenderaan itu? Peserta Orang lain b. Nama Encik/Puan/Cik c. No. Kad Pengenalan Tarikh lahir d. Alamat (Kediaman) Poskod No. TeI e. Name dan Alamat Syarikat Poskod No. TeI f. Pekerjaan g. Pemilik/Digaji oleh dari selama tahun/bulan No. Tel Jenis Perdagangan h. Apakah hubungan di antara pemandu dengan Peserta? i. Berapa lamakah pemandu telah bekerja dalam syarikat? How long has the driver been in your employ? j. Pernahkah dia terlibat dengan mana-mana kemalangan? Jika ada, sila berikan butiran k. Adakah perrnohonan insurans/takaful kenderaan bermotor pernah ditolak? Jika ada, oleh syarikat mana. l. Pernahkah dia ditahan kerana kesalahan memandu? Jika ada, sila berikan butiran m. Pernahkah lesen memandu beliau disahkan? Jika ya, sila berikan butiran beserta tarikh. n. Adakah beliau memandu dengan kebenaran anda? o. Adakah dia memiliki kenderaan bermotor? Jika ya, sila nyatakan no. pendattaran dan nama Pengendali Takaful atau Syarikat Insurans. p. No. Kenderaan Buatan dan Jenis` q. Berikan maklumat Pengalaman memandu: No. Lesen Tarikh luput r. Pengalaman Memandu oleh tahun pengalaman
4 s. Adakah anda keseorangan pada masa kecurian? Were you alone at time of loss? Ya Tidak Jika tidak, nyatakan berapa orang bersama If not, how many persons were with you? q. Berikan butiran berikut mengenai semua orang yang bersama anda semasa kecurian Nama Alamat No. Telefon Pekerjaan Hubungan dengan peserta atau pemandu 4. KECURIAN a. Masa kecurian disedari pagi / malam Tarikh b. Tempat kecurian Negeri Malaysia c. Bagaimanakah keadaan cuaca? d. Adakah ianya dalam kawasan bangunan? e. Jika berlaku pada waktu malam, adakah terdapat lampu jalan? f. Adakah kenderaan diletakkan dengan betul Adakah ia diletakkan dalam kawasan meletak kereta? g. Balai Polis di mana laporan kecurian dibuat h. Tarikh Laporan Masa i. No. Laporan Polis j. Adakah polis membuat lawatan ke tempat berlakunya kecurian? Ya Tidak Adakah saksi anda ditemubual oleh pihak polis? k. Nama orang yang telah membuat laporan polis dari No. Tel
5 5. SILA JELASKAN BAGAIMANA KECURIAN BERLAKU a. (Sila guna muka surat tarnbahan jika perlu) Sila lukiskan lakaran di bawah bagi menunjukkan kedudukan dan cara kenderaan anda diletakkan- (Sila namakan jalan atau lokasi dengan jelas)
6 6. SILA BERIKAN BUTIRAN MENGENAI KENDERAAN ANDA a. Adakah terdapat tanda khusus atau yang diketahui pada kenderaan anda bagi anda mengenalpasti sekiranya kenderaan itu ditemui? b. Adakah anda mempunyai sebarang firasat mengenai kecurian ini atau adakah anda mengesyaki sesiapa? c. Senaraikan barangan lain yang turut dicuri, jika ada. d. Nyatakan lain-lain takaful atau insurans yang masih berkuatkuasa berhubung dengan kehilangan e. Berapa banyakkah kenderaan anda pada masa dahulu yang pernah dicuri, sila berikan f. Apakah langkah-langkah yang telah anda ambil untuk mengelakkan kehilangan kenderaan g. Sebelum kejadian adakah anda telah menghantar kenderaan untuk dibaiki atau diservis? Jika ada, sila berikan nama dan alamat Mekanik/ Pusat Servis. Saya/Kami dengan ini mengakui bahawa maklumal-maklumat yang diberikan ini adalah sebenar-benarnya dan bahawa Saya/Kami tidak mempunyai sijil takaful/polisi insurans lain yang melindungi saya/kami berkaitan dengan kerugian ini. Saya/Kami juga bersetuju bahawa jika Saya/Kami telah melakukan atau diperlukan oleh Penaja Jamin untuk sebarang perakuan berhubung dengan kecurian ini, telah membuat kenyataan tidak benar atau palsu, atau sebarang sekatan atau penyembunyian, tuntutan akan dibatalkan dan segala penemuan selepas ini akan dirampas. Tandatangan Pemandu No. K.P Tarikh Tandatangan Pemandu No. K.P Tarikh Zurich General Takaful Malaysia Berhad ( U) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax:
7 Motor Vehicle Theft Claim Form Important Note: YOU ARE KINDLY REQUESTED TO COMPLETE THIS FORM IN FULL AND TO RETURN IT TO THE TAKAFUL OPERATOR WITHIN SEVEN (7) DAYS AFTER THE THEFT. PLEASE ALSO SUBMIT A PHOTO COPY OF THE FOLLOWING: REGISTRATION CARD BUSINESS REGISTRATION FORM IDENTITY CARD POLICE REPORT DRIVING LICENCE The Takaful Operator does not admit liability by the issue of this form. 1. THE PARTICIPANT a. Name Mr/Mrs/Ms/Mdm b. Identity Card No. or Business Registration No. c. Address (Residence) Post Code Tel. No. d. Business Address Name of Company Address Post Code Tel. No. e. Nature of Business f. Proprietor of/employed by of for year/month Tel. No. Nature of Trade Monthly salary RM plus monthly allowance RM Plus other income g. Cover Note Certificate No. h. Third Party Comprehensive In the event of discrepancy, ambiguity and conflict in interpreting any term or condition, the English version shall prevail and supercede the Bahasa Malaysia version. TP47/1/G CF-GCS-003
8 2. THE VEHICLE Make & Type of Body Colour Seating Capacity or Tonnage Year of Manufacture Price paid when purchased New or Second hand when purchased Registration No. Engine No. Chassis No. Vehicle Log. Book No. Diesel or Petrol Powered? a. Is the vehicle owned by you? b. Date of purchase of Vehicle c. Purchased from of d. Introduced by salesman/broker of e. If subject to a Hire Purchase Agreement, give name of H.P. company Photocopy of H.P. Agreement Attached f. How many instalments have you paid at the time of theft? Yes No g. Date of your latest instalment paid h. Takaful purchased from of through of i. For what purpose was the vehicle used at the time of the theft? j. Was it being used with your knowledge and consent? k. If a motor cycle (a) was a side car attached? (b) was pillion passenger being carried l. If a lorry (a) was a trailer attached? (b) were goods-carried? Nature of goods? m. What type of Haulage Permit (Federal) is the vehicle licensed for? Ya Tidak n. How many accidents or losses have arisen during the past THREE YEARS in connection with this or any other Motor Vehicle owned or driven by you or by any person Total No. of Vehicle owned by Participant Total No. of accidents or claims Accidental Damage Amount paid Third Party/ other claims Cost of outstanding claims Name of Insurance Co./ Takaful Co. 1 tahun lepas 2 tahun lepas 3 tahun lepas
9 3. POSSESSION OF VEHICLE a. At the time of theft, who was in possession of the vehicle? Participant Other person b. Name Mr/Mrs/Ms/Mdm c. Identity Card No. Date of Birth d. Address (Residence) Post Code Tel. No. e. Company Name and Address Post Code Tel. No. f. Occupation g. Proprietor of/employed by of for years/month Tel. No Nature of Trade h. Relationship of driver to Participant i. How long has the driver been in your employ? j. Has he previously been involved in any accidents? If so, please give details k. Has he ever been refused any motor vehicle insurance/takaful? Is so, by which company? l. Has he ever been charged with driving offences? If so, please give details m. Has his driving licence ever been endorsed? If so, please give details with dates n. Was he driving with your authority? o. Does he own a motor vehicle? If so, please plate registration number and name of Takaful Operator or Insurance Co. p. Vehicle No. Make & Type q. State details of driving Experience: Licence No Expiry Date r. Driver s Driving Experience years experience
10 s. Were you alone at time of loss? Yes No If not, how many persons were with you? q. Give the following particulars of all persons with you at time of loss Name Address Telephone No. Occupation Relationship to Participant or Driver 4. THE THEFT a. Time of theft discovered a.m/p.m Date b. Place of theft State of Malaysia c. What was the weather condition? d. Is it a built up area? e. If at night, was the road lighted? f. Was your vehicle correctly parked? Is it a proper parking place? g. Police Station to which report of theft was made h. Date of Report Time i. Police Report No. j. Did the police visit the scene of theft? Yes No Was your witness interviewed by the police? k. Name of person who lodged the police report of Tel No.
11 5. PLEASE EXPLAIN HOW THE THEFT OCCURRED a. (Use additional pages if necessary) Please draw sketches below showing the spot and in what manner your vehicle was parked (Please name the roads or locations clearly)
12 6. PLEASE GIVE US THE FOLLOWING DETAILS OF YOUR VEHICLE a. Any specific or known markings on your vehicle which could be identified by you in case your vehicle is discovered? b. Have you any clue as to the theft or do you suspect anyone? c. List other articles stolen, if any d. State what other takaful or insurance are in force on the lost property e. Now many of your past vehicles were stolen, please give details f. What precautions were taken by you to prevent the loss of your vehicle? g. Prior to the loss did you send your vehicle for repairs or servicing? If so, please give name and address of Repairer/Service Station I/We hereby declare the foregoing particulars to be true in every respect and that I/We have no other policy of insurance/certificate of takaful indemnifying me/us in respect of this loss. I/We also agree that it I/We have made or in any further declaration the Underwriters require in respect of the said theft, shall make any false or fraudulent statement, or any suppression or concealment, the claim shaft be void and all recovery thereunder shall be forfeited. Signature of Participant IC. No. Date Signature of Participant IC. No. Date Zurich General Takaful Malaysia Berhad ( U) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax:
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