UW-MT-F190

Rev : A

VEH
HICLE INSPE
ECTION FOR
RM

Insured’s Name

Vehicle No.

Cover N
Note No.

Make/Mo
odel

Purpose
e of Inspection (mid terrm endorsem
ment)
C
Conversion From
F Third Party to Increase of Sum Insu
ured
C
Comprehensiive Cover

nclusion of Windscreen
In W C
Cover Inclusion of Special Perils
P

Proposa dorsement : __________

al date of end ___________
_________

Vehicle Condition
Front Satisfactoryy Yes N
No

Rear Satisfactoryy Yes N

No

Side Satisfactoryy Yes N

No

een
Windscre Satisfactoryy Yes N
No

Engine / Chassis No. : Same as per RIMV card

c Yes N
No

I hereby declare thatt the vehicle has been insspected and confirmed in
n satisfactoryy condition.

Agent’s Name : ____

__________
___________
___________
__________
___________
___

: ____
__________
___________
___________
__________
___________
___
(Nam
me in full, Sig
gnature & Ag
gent’s Company stamp)
Date : ____
__________
______ Time : __________
_ ___________
__

Important Notes

1. T
This vehicle
e inspectionn form must be attached d together with
w photogrraphs of the
e followings
s:
a Front vie
a. ew of vehicle
e
b. Rear vie
ew of vehicle
c Side view
c. w of vehicle
d Engine serial
d. s numbe er
e Close up
e. p view of win
ndscreen (forr inclusion of windscreen cover).

2. Please referr to branche

es for appro ehicle condition is not satisfactory.
oval if the ve s .

AmGeneral In
nsurance Berha
ad (44191-P)
(Formerly Known ass Kurnia Insurans (M
Malaysia) Berhad)
A Member of the Ammbank Group
HEAD OFFICE : Me enara Kurnia, No. 9 Jalan
J PJS 8/9 46150
0 Petaling Jaya P.O. Box 8607, 46792 Peetaling Jaya, Selango
or Darul Ehsan.
Tel : +603-7875 333
33 Fax : +603-7875 9933 E-mail : corporate@kurnia.com We ebsite : www.kurnia.ccom