The Certificate ISO 9001 is only applicable to the Head Office

NO TIP
S
PL
EA
SE

FORMULIR KLAIM KENDARAAN BERMOTOR

!

WE
A RE R A K S A

Rev : 07
1. Data Kendaraan
No polisi : ......................................................................................................................................................................................
Merk dan tipe : ......................................................................................................................................................................................
No rangka : ......................................................................................................................................................................................

2. Data Pelapor
Nama : ......................................................................................................................................................................................
Alamat : ......................................................................................................................................................................................
No handphone : ......................................................................................................................................................................................
Email : ......................................................................................................................................................................................
Hubungan dengan pemegang polis : ......................................................................................................................................................................
Apakah pelapor merupakan pemegang polis : Ya Tidak
Apabila “Ya” langsung ke nomor 4
3. Data Pemegang Polis

Nama : ......................................................................................................................................................................................
Alamat : ......................................................................................................................................................................................
No handphone : ......................................................................................................................................................................................
Email : ......................................................................................................................................................................................

4. Data Pengemudi
Nama : ......................................................................................................................................................................................
Alamat : ......................................................................................................................................................................................
No handphone : ......................................................................................................................................................................................
Jenis SIM : A / B / C / B1 / B2 , berlaku sampai dengan : .................................................................................................................................
Hubungan dengan pemegang polis : .....................................................................................................................................................................

5. Data Kerusakan / Kehilangan Bagian Kendaraan

Tempat : ......................................................................................................................................................................................
Tanggal : ......................................................................................................................................................................................
Jam : ......................................................................................................................................................................................
Kronologis kejadian : ......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................

Gambar kronologis kejadian :

6. Data Kerusakan / Kehilangan Bagian Kendaraan

a. ........................................................................................................................................................................................................................................
b. ........................................................................................................................................................................................................................................
c. ........................................................................................................................................................................................................................................
d. ........................................................................................................................................................................................................................................

JAK-SEL ; Phone : (021) 7226865
JAK-UT ; Phone : (021) 29365353
Wisma BSG 3 rd Fl, Phones : (021) 2859007 - 8 (hunting) Fax : (021) 3859004 - 6 TANGERANG ; Phone : (021) 53124288
Jl. Abdul Muis No.40 Website : www.araksa.com, www.raksaonline.com BEKASI ; Phone : (021) 89452788
Jakarta 10160 - Indonesia E-mail : raksa@araksa.com, raksaonline@araksa.com BOGOR ; Phone : (0251) 8656450
BANDUNG ; Phone : (022) 7315916
SEMARANG ; Phone : (024) 3587501 MAKASSAR ; Phone : (0411) 459002 LAMPUNG ; Phone : (0721) 6016665
SOLO ; Phone : (0271) 721215 BALIKPAPAN ; Phone : (0542) 7212165 PONTIANAK ; Phone : 0812-8419-0088
YOGYAKARTA ; Phone : (0274) 4986270 BANJARMASIN ; Phone : (0511) 6743134
SURABAYA ; Phone : (031) 5329551 PEKANBARU ; Phone : (0761) 8417871
MALANG ; Phone : (0341) 410890 PALEMBANG ; Phone : (0711) 370478
DENPASAR ; Phone : (0361) 4722072 MEDAN ; Phone : (061) 4575827
 7. Data Keterlibatan Pihak Ketiga
*Diisi apabila kecelakaan melibatkan pihak ketiga

a. Penyebab Kecelakaan
Pengemudi
Terdapat tuntutan ganti rugi dari pihak ketiga Ya Tidak

Pihak ketiga
Menerima ganti rugi dari pihak ketiga Ya Tidak

b. Bentuk Pihak Ketiga

Fasilitas umum : ...................................................................................................................................................................
Properti pribadi pihak ketiga : ...................................................................................................................................................................
Kendaraan : ...................................................................................................................................................................
Korban jiwa/ korban luka : ...................................................................................................................................................................
Lain-lain : ...................................................................................................................................................................

c. Informasi Pihak Ketiga

Nama : ...................................................................................................................................................................
Alamat : ...................................................................................................................................................................
No handphone : ...................................................................................................................................................................
Nama asuransi ( apabila ada ) : ...................................................................................................................................................................

8. Data Saksi-Saksi Kejadian

Nama Alamat No handphone

a. ..................................................... .............................................................. .........................................................

b. ..................................................... .............................................................. .........................................................

9. Nama Perusahaan Asuransi Lain Yang Juga Mengcover Asuransi Atas Kendaraan Yang Sedang Diklaimkan
............................................................................................................................................................................................................................................

Saya menyatakan bahwa keterangan-keterangan yang diuraikan diatas adalah benar dan saya juga bersedia memberikan
segenap bantuan kepada perusahaan asuransi sehubungan dengan proses klaim ini. Apabila ada keterangan yang
tidak benar, saya bersedia menanggung seharusnya dilanjutkan dengan konsekuensi sesuai ketentuan berlaku.

Dokumen yang perlu dilampirkan :

- Foto copy SIM, STNK, dan KTP (Pemegang Polis, Pengemudi, Pelapor)
- Foto copy Polis Asuransi
- Surat Keterangan Polisi (bila diperlukan)

Tanggal ......................
Tanda Tangan Pelapor

(....................................................)
Nama Jelas

JAK-SEL ; Phone : (021) 7226865
JAK-UT ; Phone : (021) 29365353
Wisma BSG 3 rd Fl, Phones : (021) 2859007 - 8 (hunting) Fax : (021) 3859004 - 6 TANGERANG ; Phone : (021) 53124288
Jl. Abdul Muis No.40 Website : www.araksa.com, www.raksaonline.com BEKASI ; Phone : (021) 89452788
Jakarta 10160 - Indonesia E-mail : raksa@araksa.com, raksaonline@araksa.com BOGOR ; Phone : (0251) 8656450
BANDUNG ; Phone : (022) 7315916
SEMARANG ; Phone : (024) 3587501 MAKASSAR ; Phone : (0411) 459002 LAMPUNG ; Phone : (0721) 6016665
SOLO ; Phone : (0271) 721215 BALIKPAPAN ; Phone : (0542) 7212165 PONTIANAK ; Phone : 0812-8419-0088
YOGYAKARTA ; Phone : (0274) 4986270 BANJARMASIN ; Phone : (0511) 6743134
SURABAYA ; Phone : (031) 5329551 PEKANBARU ; Phone : (0761) 8417871
MALANG ; Phone : (0341) 410890 PALEMBANG ; Phone : (0711) 370478
DENPASAR ; Phone : (0361) 4722072 MEDAN ; Phone : (061) 4575827