9114123, 2:15 Pat Claim Fo MOTOR VEHICLE CLAIM FORM (him No, No: PR-10484711 PACIFIC & ORIENT INSURANCE CO.BERHAD = CLAIM FORMTAKEN ON: 14092023 “Tan Shang BP poh Sa, Bhd. IN ORDER THAT WE MAY GIVE YOU PROMPT SERVICE IN CONNECTION WITH THE ACCIDENTILOSS REPORTED TU CS WILL YOU KINDLY COMPLETE THIS FORM 1. The lnsure, 2,__The Vehicle Insured, TE RTCAGT a own 1x22 2016 0% co ean SEEN | sos nour ©) Wadgeamattic rasta Apes ge nee TL _ ates ©) yaaa ae Intps:hwww merimen com my/laimstindex cfnfuseboxsMTRinsurer&fuseaction=gen_prnteimform@inclayout=T&caseld=156126498CFI0=1912... 149/14/23, 215 PM (Claim Form 3. Person driving tthe time of Accident. (0) Warts ving ems erence en plas gh uw dias 4 The Accident (0) Whar aot os? A sane onto _z05 “ oot (0) thet ay ah (8) fess cua afer ining 9 sn se Wage nad Whi hl an ghee 912. 24 hitos/Awwer merimen.com my/claimsiindex.cfr Musebox=MTRinsurer&fuseaction=gen_printelmform&nolayout=18caseid=156126498CF I9714/23, 215 PM (Claim Form No: PR-10484711 S. Witnesses https ziwww.merimen.com mylciaims/index cfm fusebox! (TRinsurerdluseaction=gen_printcimformS&nolayout=1&caseid=156126498CFID=1812... 349114/23, 215 PM (Claim Form No: PR-10484711 6. Responsbilly for Accident. ‘Own Damage. Third Parte, 0 Osa Ther hips uAwur merimen.com my/claimsiindex cfm tusebox: 1561 26498CFID=1912... 44