Borang Laporan/Tuntutan Kemalangan Kenderaan Motor AGENSI NO. TUNTUTAN NO. SIRI ta Penting Syarikat tidak mengakui sebarang tanggungan dengan mengeluarkan borang ini Jangan mengakui tanggungan kepada sesiapa dan sebarang tuntutan secara bertulis atau lisan mesti dimaklumkan dan dibawa ke perhatian Syarikat. Jika tuntutan adalah untuk kos pembaikan kenderaan anda (di bawah Seksyen 1 Sijil), anda perlu menghantar kenderaan anda ke balai polis. Kebenaran bertulis mesti diperolehi daripada Syarikat sebelum kerja pembaikan dimulakan. Sila lampirkan dokumen-dokumen yang berikut bersamasama borang laporan / tuntutan ini. 1. Salinan Sijil 6. Salinan Laporan Polis yang disahkan 2. Salinan Lesen Memandu Pemandu 7. Salinan Taksiran Bengkel Membaiki Kereta 3. Salinan Kad Pengenalan Pemandu 8. Salinan Perjanjian Jual Beli, jika ada 4. Salinan Kad Pendaftaran 9. Borang Pendaftaran Perniagaan (hanya bagi kenderaan milik Syarikat 5. Salinan Cukai Jalan 10. Gambar tempat berlaku kemalangan 1. PESERTA Nama: Encik/Puan/Cik. Kad Pengenalan (Baru) (Lama). Pendaftaran Perniagaan Alamat Rumah Poskod Alamat Pejabat Poskod Perniagaan atau Pekerjaan. Telefon Pejabat Rumah. Telefon Bimbit E-mel. Sijil Tarikh Luput Komprebensif Pihak Ketiga 2. PEMANDU (anda sendiri jika anda yang memandu) Nama: Encik/Puan/Cik. Kad Pengenalan (Baru) (Lama) Alamat Rumah Poskod. Telefon Bimbit Umur E-mel Pekerjaan Hubungan dengan Peserta
Adakah beliau memandu dengan kebenaran anda?. Lesen Memandu Tarikh lesen Luput Adakah Lesen Penuh atau Lesen Sementara? Kelas (Kelas-Kelas) diiindungi Pengalaman Pemandu tahun memandu. Tarikh lulus ujian memandu Pernahkah Pemandu didapati bersalah kerana kesalahan berhubung dengan memandu Kenderaan Bcrmotor? Jika ya, berikan butir-butir ringkas dan tarikh (tarikh-tarikh) Pernahkah Pemandu terlibat dalam Kemalangan sebelum ini? Adakah Kenderaan yang diiinsuranskan di bawah Perjanjian Sewa Beli? Jika ya, dengan siapa? 3. KENDERAAN Jenis dan Model Tahun Pengeluaran. Pendaltaran Adakah disambung Treler? Untuk apakah kenderaan digunakan? 4. KEMALANGAN Tarikh Kemalangan Waktu pagi/tengah hari/malam Tempat kemalangan Berapakah kelajuan kenderaan anda semasa kemalangan berlaku? Adakah anda berada dalam kenderaan? Jika tidak, bilakah kemalangan dilaporkan kepada anda? Jelaskan dengan tepat bagaimana kemalangan berlaku (Tolong jangan tulis Rujuk kepada Laporan Polis )
PELAN KEMALANGAN Sila tunjukkan dengan sejelas yang boleh anggaran jarak sernua jalan di sekitar tempat kemalangan serta kedudukannya, dan dengan menggunakan anak panah, haluan pergerakan semua kenderaan yang terlibat. SEBELUM SELEPAS 5. MAKLUMAT POLIS Balai polis di mana laporan dibuat. Laporan Adakah anda menerima notis hasrat untuk mendakwa atau saman? Jika ya, apakah kesalahan yang anda lakukan? 6. SAKSI-SAKSI Nyatakan nama dan alamat saksi-saksi kemalangan 7. KEROSAKAN KEPADA KENDERAAN ANDA Berikan butir-butir penuh kerosakan kepada kenderaan anda Give full details of damage to your vehicle Berapakah anggaran kos membaikinya? (lampirkan taksiran pembaikan) Nama dan alamat bengkel yang membaikinya. Telefon 8. BUTIR-BUTIR PIHAK KETIGA (a) Nyatakan nama dan alamat kenderaan lain yang terlibat dalam kemalangan:- (i). Pendaftaran (ii) Nama Pemilik Nama Pemandu Alamat (iii) Nama Pengenali Takaful atau Syarikat Insurans dan. Sijil atau Polisi (b) Nyatakan nama, alamat setiap orang yang cedera, umur dan butir-butir kecederaan Nama Umur Alamat Butir-butir Kecederaan
(c) Adakah crang (orang-orang) yang ceders ditnasukkan ke hospital atau dirawat sebagai pesakit luar (d) Nyatakan nama dan alamat hospital / klinik: (e) Berikan butir-butir kenderaan atau harta benda lain yang rosak (selain daripada kenderaan anda sendiri) Sebarang surat yang anda terima berkenaan kemalangan ini hendaklah dihantar kepada Syarikat dengan serta-merta tanpa menjawabnya. 9. TANGGUNGJAWAB TERHADAP KEMALANGAN Siapakah yang anda anggap bertanggungjawab terhadap kemalangan itu? Mengapa? Jika kemalangan disebabkan kecuaian mans-mana orang (orang-orang) lain, berikan nama (nama-nama), alamat (alamat-alamat) mereka dan nombor (nombor-nombor) pendaftaran kenderaan Adakah tanggungjawab diakui oleh salah satu pihak? Sudahkah pihak polis mengambil tindakan ke atas pemandu? Jika ya, berikan butir-butir. Saya/Kami dengan ini mengisytiharkan bahawa butir-butir di atas adalah benar dalam segala hal dan bahawa Saya/Kami tidak mempunyai Takaful atau insurans lain yang melindungi Saya/Kami berhubung kemalangan ini. Saya/Kami juga bersetuju bahawa jika Saya/Kami telah membuat atau dalam sebarang perisytiharan sclanjutnya yang dikehendaki oleh Penaja Jamin berhubung dengan kemalangan tersebut, membuat sebarang kenyataan palsu atau penipuan, atau menahan atau menyembunyikan sebarang fakta berkaitan, tuntutan bagi kemalangan tersebut adalah tidak sah dan semua pembayaran ganti rugi akan dibatalkan. Tandatangan Pemandu. K/P Tarikh Tandatangan Peserta. K/P Tarikh Sekiranya terdapat kekeliruan, kekaburan den konflik dalam pentafsiran mana-mana terms atau syarat kontrak ini, versi Bahasa Inggeris adalah terpakai dan mengatasi versi Bahasa Malaysia. Zurich General Takaful Malaysia Berhad (1260157-U) 11th Floor, Menara Zurich,.12, Jalan Dewan Bahasa, 50460 Kuala Lumpur, Malaysia Tel: 03-2146 8000 Fax: 03-2144 0352 www.zurich.com.my
MOTOR VEHICLE ACCIDENT REPORT/CLAIM FORM AGENCY SERIAL NO. Important te The Company does not admit liability by the issue of this form. Claim. t Do not admit liability to any person and any written or verbal claims must be notified and brought to the Company s attention. If the claim is for the cost of repairs (under Section 1 of the Certificate) to your vehicle, you are to send your vehicle to the police station. The workshop which undertakes to repair your vehicle must be one approved by Zurich Takaful Berhad. A written consent must be obtained from the Company before commencement of repairs. Kindly attach together with this report/claim form with the following documents:- 1. Copy of the Certificate 6. Certified Police Report 2. Copy of Participant s and/or Driver s Driving License 7. Copy of Repairer s Estimate 3. Copy of Participant s and/or Driver s identity Card 8. A copy of the H/P agreement, if any 4. Copy of Registration Card 9. Business Registration Form (for compaay owned vehicle only) 5. Copy of the Road-Tax 10. Photograph on the scene of accident 1. THE PARTICIPANT Name: Mr/Mrs/Ms/Mdm. Kad Pengenalan (Baru) (old) or Business Registration. Home Address Post Code Office Name and Address Post Code Business nature or Occupation Office Phone. House Phone. Handphone E-mail Certificate. Expiry Date Comprehensive Third Party 2. THE DRIVER (yourself if you were driving) Name: Mr/Mrs/Ms/Mdm NRIC NO. (New) (Old) Alamat Rumah Post Code Handphone Age E-mail Occupation Relationship to Participant
Was he driving wit with your permission? Driving Licence. Expiry date of licence Is it a Full or Provisional Licence? Class(es) covered Driver s Driving Experience years experience. Date driving test passed Has the Driver ever been convicted of an offence in connection with the driving of a Motor Vehicle? If so give brief details and date(s) Has Driver previously been involved in an Accident? Is the insured Vehicle under Hire Purchase Agreement? If so, please provide name, address and contact number of the hire purchase Company? 3. THE VEHICLE Make and Model Year of Manufacture Reg. Was A Trailer attached For what purpose was the vehicle being used? 4. THE ACCIDENTS Date of Accident Time am/pm Place of Accident At what speed was your vehicle travelling at time of occident? Were you in the vehicle? If not when was accident reported to you? Explain exactly how the accident occured (Please do not write Refer to the Police Report )
PLAN OF ACCIDENT Please indicate as clearly as possible the vicinity of the accident with indication of the position by means of arrows and direction of progress of the all vehicles involved. BEFORE AFTER 5. POLICE INFORMATION Police station to which report of accident was made Report Have you received notice of intended prosecution or summons? If so, what is the nature of the offence? 6. WITNESSES State names and addresses of witnesses of the accident. 7. DAMAGE TO MAKE VEHICLE Give full details of damage to your vehicle What is the estimated cost of repairs (attach repair estimate) Name and address of repairer Telephone. 8. THIRD PARTY DETAILS (a) State name and address of owners of the other vehicle involved in the accident:- (i) Registration (ii) Name of Owner Name of Driver Address (iii) Name of Takaful Operator or Insurance Company and Certificate or Policy (b) State names, address of every person injured, their age and nature of injuries- Name Age Address Nature of injuries
(c) Was the injured person(s) warded or treated as outpatient? (d) State name and address of hospital/clinic: (e) Give details of vehicle or other property damaged (other than own vehicle) Any communications you receive regarding this accident should be sent to the Company immediately unanswered 9. RESPONSIBILITY OF THE ACCIDENT Whom do you consider was responsible for the accident? Why? If the accident was due to the negligence of any other person(s), give their name(s), addresss(es) and vehicle number(s) Was responsibility admitted by either party? Has the police taken action against the driver? If give details: I/We hereby declare the foregoing particulars are true in every respect and that I/We have no other Takaful or insurance indemnifying me/us in respect of this accident. I/We also agree that if I/We have made or in any further declaration the Underwriters require in respect of the said accident, shall make any false or fraudulent statement or any suppression or concealment, the claim shall be void and all recovery thereunder shall be forfeited. Signature of Driver NRIC Date Signature of Participant NRIC Date In the event of discrepancy, ambiguity and conflict in interpreting any term or condition of the contract, the English version shall prevail and supercede the Bahasa Malaysia version. Zurich General Takaful Malaysia Berhad (1260157-U) 11th Floor, Menara Zurich,.12, Jalan Dewan Bahasa, 50460 Kuala Lumpur, Malaysia Tel: 03-2146 8000 Fax: 03-2144 0352 www.zurich.com.my