035/TMP/CMD/04/2021/v.

SURAT KETERANGAN KETERLAMBATAN LAPOR

Policy No : ____________________________
Insured Name : ____________________________
QQ Name : ____________________________
Plat No : ____________________________
Type : ____________________________

No Klaim : ____________________________
Tgl Kejadian : ____________________________
Kronologis : _______________________________________________________________________
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_________________________________________________________________________
_________________________________________________________________________
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Alasan Keterlambatan pelaporan klaim :

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Tgl ____/______/_________

(_______________________)
Ttd, Pemegang Polis / Insured.