REQUEST LETTER FOR REPAIR TO NON-ACCREDITED SHOP

I, _____________________________________, would like to request that my vehicle be repaired at my

preferred repair shop _____________________.

Reason: _______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Details of the claim are as follows:

Assured: __________________________________________________________

Third Party: __________________________________________________________

Policy No. : __________________________________________________________

Make & Type : Insured Unit _____________________________Plate No.______________

Date of Loss: _______________________________________________________________

Place of Loss: ________________________________________________________________

Thank you,

__________________________ VB

Signature over printed name

Valid Government ID submitted: _____________________________

TO BE FILLED UP BY THE CLAIMS HANDLER

Claim No. : _________________ Type of Claim: OD TPPD

Claim Evaluation (Net Company’s Liability): ________________________________________________

Remarks: _____________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Evaluated by: Approved By:

________________________________ ____________________________________