(To be completed if Insured makes 2 Knock-for-Knock claim under his own insurance policy) Letter of Declaration To: AXA Affin General Insurance Berhad Re: Insurance PolcyiCover Note No: _ 76505258 ‘Accident on _ 29/06/2021 involving my/our vehicle No. _MN2507 and third party vehicle No, _WiraH7 We the undersigned do hereby solemnly, sincerely and unconditionally declares. 2) That the claim submit under Accident Report Form No. Is a Knock-tor-Knock claim fr repairs to mylour ‘above vehicle which was damaged in the above accident as provided for under “tem 2(b) of Accidents and Claims. ProcoduresiCondition 3 ofthe Policy. 'b) That report about the accident had ween lodged by *methe driver of myour vehicle t Police Staion TRAFIC LEDANG {name ofthe station) vide report number {01877/21__ (potice report no). ©) Thatthe registration numberof the thir party vehici is W172 )—_Thatthe circumstances ofthe accident as reported to the police and to M/S AXA AFFIN GENERAL INSURANCE BERHAD are true. : ‘e) hatte accident was caused solely due tothe negligence ofthe driver ofthe third party vehicle, 1) That “ithe driver of mylour vehicle was not charged by the poce for any offence relating tothe accident. 19) That the agree that the No Clsim Discount (NCD) will be automatically forfeited iit is subsequently discovered that the accident was due to the fauBInegligence of mathe driver of my/our vehicle and that such determination of fautnegligence shal be atthe ‘entire discretion of W'S AXA AFFIN GENERAL INSURANCE BERHAD. hh) Thata licensed adjuster wil be appointed by M/S AXA AFFIN GENERAL INSURANCE BERHAD to conduc an inspection of the Vehicle and no repairs may be authorized tothe vehicle without the Insure’ writen consent ‘Signature of Insured % e ‘Signature of wines. Name ctinred = ERE Na nee te wenn ee one ae 8. No, Date (For Insured who isan incoporated body, please sign with Company stamp) “Delete whichever s not applicableANA Affin General Insurance Berhad (197501002042) Ground Floor, Wisma Boustead ‘No7! Jalan Raja Chulan 50200 Kuala Lumpar (603) 2170 8282, (603) 2031 7282 E customer service@axa.commy Service Tax Reg. No.:W10-1808-31015017 Motor Insurance Claim Form oo | ‘To speed up the process, please (1) Complete this form, (2) Prepare the relevant documents licted on page wo, and (3) Mal Uiem to AKA ‘Ofice a8 soon as possible. Thank you. < INSURED & DRIVER DETAILS — em TER FETE a a 2 aS vet SSS mca saa SRT UT CERN BOTS or Dvd TED goer fo : Pate of Reraon a en eines neon am [AN § TAMAN SEROM UT * Driving License Number ofthe person driving the carat time of accident: 19035874 VEHICLE DETAILS (Citake PEROOU Model Riya 2005 OF [Registration No, UWNZEOT 1 LOSS DETAILS es TaN MUARSEGANAT type ot |L) Own Damage ‘Own Damage! Knock for Knock (Windscreen Damage fe then G_ Notiteation only anybody Polis =m OD vestrorce “ c ‘nett [Coven Cane Repet | veurotee Reporte: earwaeoanaioourrat) No Description | Pam oa aaa i AA AIT ATS STOR RESET ARTA SRT A AA. TT of Lokay | mcnann uneven nner ‘Accident nator par ‘peeeatne it accident taTned BOOT Try oF TH Party Property Damaged, lease complete the Annexure 7 D. BANK ACCOUNT DETAILS . Please provide your bank detalls for us to accelerate your claims payment process by direct transfer to your bank account, ‘Nam {as per bank Bank Name ‘secount) Recount No- Bank Branch Payment advice willbe sent To your email Pease check M your emall address is given Tn Section A, E, DECLARATION & CUSTOMER'S DATA PRIVACY NOTICE Declaration) We hereby declare that the above statements and facts are true, copies of documents are identical with the original ‘one, and that [We have not withheld from the Company, any Information within mylour knowledge connected with the accident. [Cuhtomer's Dots Prvacy Notice] AXA Affin General naurance Berhad ls committed to protect the personal data submitted by and ‘collected from you. For further deals, please refer to our ‘Data Privacy Notice” published in our website, Signature of Insured: x55" Dat:Appendix 1 AXA Affin General Insurance Berhad (197501002042) Ground Floor, Wisma Boustead = No 71 Jalan Raja Chulan 50200 Kuala Lumpur (0 (603) 2170 8382, (603) 2031 7282 E customerserviced@axa.com.my Service Tax Reg, No: W10-1808-31015017 BODILY INJURY OR THIRD PARTY PROPERTY DAMAGE QUESTIONNAIRE Please complete this form {and submit with the clalm formar Thank you. + BODILY INJURY rs = ae caren aT ; NIL rapa —] Paar on a re er Settee |UNKNOWN =| UNKNOWN WTF8870 UNKNOWN TOYOTA VIOS “W space is InsuMicient, please give details in» separate paper. We hereby declare thatthe above statements and facts are true, copies of documents are identical with the crignal one, and that IW have not ‘withheld rom the Company, any information within myiout knowledge connected withthe accident, Date: ‘Signature of river: reer ‘Signature of insured (not aver: oi