File Ref: ……………………………………………………………………

Client: ……………………………………………………………………

Date:

Re: Accident on

I ……………………………………………………………….………. I/C No.

………………………………………………… of

………………………………………………………………………………………… to accept the offer of

…………………………… (Ringgit Malaysia …………………………………………………………………………)

as damages in full and final settlement of my claim herein.

……………………………………………………..

Witnessed by:

……………………………………………………..