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  • Motor Accident Report Form PDF

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    1. Motor Accident Report Form.pdf

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    217 visualizzazioni7 pagine

    Motor Accident Report Form PDF

    Caricato da

    Venodaren Velusamy

    Copyright:

    © All Rights Reserved
    Scarica in formato PDF o leggi online su Scribd
    Segnala contenuti inappropriati
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    Allianz General Insurance Company Malaysia Berhad (735426. Allianz @ MOTOR ACCIDENT REPORT FORM TNPORTANT CONTACT DETANS = INSURED MOBIEN: DRWERS MORLENO™ INSURED EMAIL ADORES= DRWERS EMAL ADDRESS= FOR OFFICE USE ONLY Tdjuster Dae “This claim form ie issued to Appointed (oame af agent/oroceripotiyholer) | Raaeday Date Noted Cause fos Relationship oy “oun Gam Chim No (name of sai) (idibranchconcemed) [Code Reson Code reser Authorised Signatory ate IMPORTANT: I's important that his form is fly completed, cul signed and returmed together wit he required documents as soon as possible but not later than 14 gays from the date of receipt of ths form. This form i seued on awthout prejudice basis and not an admission of Habity onthe pat ofthe company. TYPE OF CLAIM Please tick (V7) where applicable A Oanbanage Dy Netieaton=Caiming Agana Tara Fany B)_Thet of vetice Acenores ©) juryto Third Party ©) Windscreen Damage Damage to Tired Pary Proper vende PARTICULARS OF INSURED NE ‘OCCUPATION BUSINESS: ADDRESS OFFICE PHONES FICE ARN HOUSE PHONE NG POUCY/COVERNOTENO PERIOD OF INSURANCE TYPEOF COVER Comp Td Pany INSURED ST DETAILS "AREYOU REGISTERED FOREST? Coe L1xo EVES PLEASEPROVDE: —_GSTREGISTRATION DATE GSTREGITRATIONNO TE YOU ARE ABUSINESS ENTITY, ARE YOU ASOLE PROPRIETOR? Ces Tne ISTHE DAWAGED/LOST ITEM(S) USED FOR Tnuswesss NON BUSINESS Chom WILL YOURE CLAIMING OR INTEND TO CLAMIINPUT TAX CREDIT? Cos Tine PARTICULARS OF THE DRIVER Na TE ‘OCCUPATION BUSINESS TODRES OFFICE PHONENG: FICE FARN: HOUSEPHONENG DRIVING EXPERIENCE YEARS ASS PARTICULARS OF ACCIDENT/THEFT RECISTRATIONNO. MAKE/MODEL (air Na) DATE OF ACCDENTTHERT i mar ACE OF ACCIDENT THEFT MILESTONE ROAD NAME & TOWN POUCESTATION REPORTING soars ‘ay ea en ae 00 farses 20018 woman Elon chances 1 ‘THE DRIVER AT THE TIME OF ACCIDENT/THEFT (Uf insured is ving ignore Question 1&2) 1) What yourrelationship withthe insured? If friend howlong hae youknownthe Insured andhow often doyouuse the vehicles? 2), Who gaveyoupermisionto we the vehi? 3) _Doyousutertrom anyphysical sabi? NoYes pease describe 4) Forwhatpurpase was the vehicle being used at thetime of accident? 5) Haveyoutaken any aeohol ar drugs prior tothe accident? No! Yes 1) Haste vehicle or any vehicle med by you ever been involved in any motor accident inthe past 3 years? NoYes ifyes: Registration No Insurance Co hea Date 7) Haveyou ever being charged or suspended by the police orb the Court (in the past3 years) or any offences? No Yes lyes: What ithe charge offence: — pate 4) Hasthe engine ofthe vehicle been modified or replaced or converted to enhance orincrasethe performance agsnst the manufacture’ specification? No 1 Yes -please provide details 9) Doyouhave any witness tothe accident? No Yas -Name and address 10) Have youever been refused any Motor Insurance? No /Yes ies please provide deals 11) Have youentered into any agreement forthe sale ofthe vehicle? No J Yes ifyes pease provide deta ‘THE ACCIDENT (Not applicable to theft of vehicle or windscreen damage) 1) Whatwas the weather and oad condition? 2). Direction of travel: From, te. 3) Speed prortothe accident: bon fhe 4) Wasthe police at the scene of accident: No Yes 5) Haveyoubeen charged bythe Police? No / Yes ~Ifyes, whats the charge/otfence? (Please extend a copy ofthe summons tous) 6) Which partothe vehicle is damaged? 7) Was nyonein the vehileinjred? No / Yos-Ifyes pease provide deta 4) Who dd you athorsetoremovetow the vehicle om the scene of accident? 9) Name & address of workshop where we can inspect your vehicle? ease draw a sketch showing the scene of acident including name of roads, postion of vehicle and direction of travel with arrows BEFORE AETER (ease mark's atthe point ofimpact) Full description of th circumstances leading tothe aceidenttheftwindscreen damage ‘THEFT OF VEHICLE 1, lethe vehicle lacked? No/ Yer Ifna please cay 2, _Isthevehcle still under Hire Purchase? No /Yes yes: Name of Company. Toho, [ACCIDENT INVOLVING THIRD PARTY 1, Damage to Third Party Motor Vehicle Registration No. Make & Model Damages Name Of Insurance Company 2, other Third Party Property Damage Lamp Post orTelephone Post Traicight Road Divider others: 3. njuty to Third Party please provide the following information Name and Address Vehicle No. Age Nature Of injuries We declare that the foregoing answers are true and complete ané that /We hold no other poiyinderlying me usin respect of his claim. |WWe request you to deal on mylour behalf with the third party claims arising herein in accordance with the terms and condition othe hove mentioned policy ané We 2uhorse you and your solictors on my/our behalf to make such admissions and settlements and give such consents as you may consider necessary forthe disposal of such claims and ay ligation arkng therefrom, Insured’ Signature Driver's Signature ste ate Allianz General Insurance Company Malaysia Berhad 73526. Allianz @ DATA PRIVACY NOTICE & CONSENT FORM (DEATH CLAIMS) / BORANG NOTIS DATA PRIVASI & PERSETUJUAN (TUNTUTAN KEMATIAN) 1. Processing of Your Personal Data / Pemprosesan Data Peribadi Anda ‘Alan General insurance Company (Walesa) erhad (‘Company’) wil use te information you supply i the Death lam Form to, mong thers, process your clam in accordance with he Personal Data Protection Act 2010, the related legisaton, the Company's andor ts Group's own sit internal poy. Allanz Generalinsurance Company (Malaysia erkod (Syria) akan menggunakan maklumatyang onde bekalkan dala Goang Iunttan Kerman untuk antarary, mernproses tartan anda engi Ata Perindungan Data Peribad 2010, andang-undang lan yang berkaten dan pols dalaman Syria danfatu Kurnpulanny sendiyang kta “The personal infarmaton supplied by you wil ircude ply information, franc nfrmation and sensitive personal data about you and the deceased which include isformaton on physal or mana heath ar medical condition or eigous els (Personal Oat’). Motumatgerbod eset sorada yang dbeklkan leh endo atev oh keluarga ano yong an, akan termasak maklumat pals, kewangan dor dota penbcl sens berkenaon onda dan mana-anaahlifeluarga anda merongkumi maktumatberkaitankeshatan fl cau ment keadoan perubtan atu epercaycon agama seranya mereka juga dindung dba insurans yang mara suatuturtutan dbut (‘Dat Perbod) “TheCopanyayalso cian youPetsonalData om athe sources suchas bureau’ agencies establshedor tobe established by regulatory autores, operators of esters or databases avalabl tothe insurance industry; ther exteral database supplies, governmental departments agencies or authorities ary party ‘winohas, desor ill provide procucsorseicesta you and ro whom you hae granted consent the Company's commercial ares, rsuranceintermeiaris, reinsurers and thd party adriisates andr service provider, other insurance compares, atterding doctrs, oso, circ, other medial professors, facies orpharmaces,worksops lawyers and agensthat have knowledge of the deceased or record in respect hereof or who had attended or treated the deceased (asthe case may be), proposed asignees, group palighoers, and raed persons or arganizaton rom whom such information wauld be essental forthe prope: processing the dara forthe pupases a sated herein. |Syrkat mungkia memeraeh Data Peribad anda daripeda sumbersumber lan, epet tire ateu agens-ogensi yang dhubuhkon ata akan dtubuhkan oleh pak berkusa aval sla, operator reted atau porgklon dat yang terse kepada dust insurans taupembekal embetalpangkoon datalur, bata keen, gens atau pibokberosa mana-manapitakyangtelah sedang atau akan membekalkan produ cau that kepada anda don kepade ipa yang onda tech memberika persetyjun, rakorrakan homers Syria pak perantrainsuans,pihak _eranggunginsurans semua pergurus dn/ataupembekl perdhidmaton pak keto, syria nsuans yong ain, doter perowat spt nk, hl profesional perubatan ain Kemudahon ata armas perubaton yang lan benakelpequam, agen yong mempunyaipengetahuantertng sat atau reked yong bekaan ctu ssipaytrg telah memerksa atau merawatsimat yong mana berkaitn),pemegengseroh hak yang dcadangkan pemunyo ps berarpulon atau orang-orang yang berkaon atu orgonsas daripede mana matluma ebegtuadaloh perting uruk empressan data yang sepoutrya untuk yuan yang dnyacakan ds 2. Impact resulting from failure to supply information /Akbatdaripada kegagalan untuk membekalkan maklumat ‘You may choose whether or not to provide your Personal Data to the Company Howeve, fare to supply your Personal Data as requested may esultin the Comparybeingurabe to evalace you air, which ay ead to your dai being dered. Hence ts obligatory far you to provide the Crmpary you Personal Data when you choose tomake alam in tespect of apaliy with te Company. Ando bleh mem sama ada hendak memberitan Data Perbad onda kepada Syankootautiak Woaubagammanapun, kegagalan untukmemberkan Dota Perbadianda seperiyang dminta mungkin akan mengokbakan Syorkt dak dapat ‘meni tutta anda yong mona boleh menyebablantuttan anda dla Dengan it adalah menadebbgsiando untuk membetalan pada Syarkt Data ferbadandoopobiaando emit untuk membuat tuntutan erode pois dengan Syarkat. For the purposes of evaluating and administering daims,the Company may ao rely on this authorization to disclose information about the deceased to the authorized third pares otha they may conduct hea care operations, dais payment, adnistave and aut futons elated tothe deceased's bent Pian, any. Bayan penain dan prtodbran cunt, Sankar jug oleh berganturg kepad persetyivan nant mendedabkan mall berenaans mat kepade pba eta yong der kuosa supay mereka dapot melon operas keshatan,bayrantntton,pntadian dan fungs aut berkaitan dengan anf smat jk edo 3. Purposes of cllecting and Using Your Personal Data / Tujuan Mengumpul dan Menggunakan Data PeribadiAnda Your an the deceased's Personal ata willbe collected, used and otherwise pracesed by he Company forthe folowing purposes: Date Prbad ando akan dikumpul digua dan sebalinya proses lh Syaitat untuk tyuan-yuan ber (0) forclaims processing, evaluation administration and cla settement:/ unk mempresstantutan meni mentadbir dan peyeesian unto (6) for detection and prevrtion of criminal actty or aud in connection with an insurance transaction anor improper cm; /untak mengesan dan rmengelal4an aki enayah atau penpuon berkitan dengan wansos iesurans danfatu tuntutn tid bet (¢)twensurethat tre Company's records are updated: urtuk memaskanbahawarekodSjarkatadla eri (9) forstastical analysis and surveys untuk analiss sts dan ka sel (2) fordatatranste to, and sharing with other members ofthe Group andor ti parties acting on behalf of the Company including thse located outsie Malaysia. untuk pemindohan dat kepada, dan berkongs dengan, alain dolar Kupulandanjatau pak etiga yang bertindok bag pihak Sanka, termasu yang berod due Malaysia. 4. Disclosure of Your Personal Data /Pendedahan Data Peribadi Anda ‘Yur and the deceased's Personal Data may aso be disclosed to authorized thir parties including ater insurers, brokers, credit organizations, underwriters, eadorce ae Mena Sal 20a up Sah Kaa LunparSeta OUD Luroa “aod ee ae zee a 1205225 138 ovelonzconry Wwlncoskcorlasa Castors Sevce Ale ra Gund os ci 2A PaaS a seen Seva KusaLumpy Sea SO470Kio Lurou ‘Man oman" 30068 dea es abt 9 Enacaomersevcesioncam my azionss reinsurers, group potyholders, benefit partners regulatory authorities, bureau or agencies established o tobe established by requlatory authorities, operators of regi lan adminis ors, thase to whorn the Cormpany outsource certain business operations Company's commercial or databases avalable tothe insurance industry os adjusters, lawyers, aucitors, persons conducting actuarial or research stuces, accountants, consultants, surveyors, externa las data collectors, ivestigators and medical professionals, and any ather contractors or sub-contractors as required or permitted bylaw ora we may decertine to be necessary or appropiate | Data Pribad anda dan simat juga bleh aidedabian kepada pihakketiga yang dber kuasa termasuk syria insuran yang lan broke, ‘rganisos-organsas ret pengunderait pihok enanggunginsurans semua, pemunya posi bertumpulo,phak pengurusanpelon manfaat kepada merekayang ‘mana Syarka telah menyumber luar operas isnes yng trent, rakaneokan komersi Sarita, pihakberkuaso kaw sei bre atau agensiyang telah atau akan ditubunke perl atau bersesuaiar oleh pihak berkuasa Kava ela, operator rekod atau pangkolan deta yang tesedia Kepada indus isurans, penelaras erugia, peguam juruaudl, mereka yong melatsanakan penyelikan oltuan atau kaj slik okauntan, pakorrunding, peninau, pengumpul dota tuntutan lr, peryasat don profesional perubatan dan mana-man kentrakor atau sub-kontaktor lain yang diperlukon atau dibenar\an oleh undarg-undang ata yang aputuskan oleh Karn sebagah 5. Your Rights of Access to Your Personal Data / Hak Anda Untuk Akses Kepada Data Peribadi Anda You have the right 1 request in writing access to, enquire and complain in respect of your Personal Data held by the Company by contacting the Company's (Customer Service Ofcer at 1300-88-1028 rom 8.45 arm, 0545 pm, Monday Friday or eral atcustome service@al acorn rmyor via our Fx No.03-2264 2498, You aso ha kepada, membu Pelanggan Syonkat ai 1300-88-1028, don 8.45 pagihinaga S45 petang, nin hinggalumaat atau en aks 03-22648489, nda juga boleh mer 92-opa pertaryoan at tasecora ber is kepadoSyarikat untuk bechent memproses Data Peribad anda 6. Information About Another Person / Moklumat Berkaitan Orang Lain the right to request in writing forthe Company ta cease processing your Personal Data. | Anda berhak untuk memintasecarabertulsakses acuonberkaiton dengon Dota Perbadi onda yang dsimpan och Syarkot dengan menghubungiPegawa Perkidatan kepada customer senice@alianzcommy atau melalui No \When you give the Company information about anether person, you confirm that they have appointed you to act for them to consent to the processing oftheir personal dataandtorecewe on their behal any data privacy natices.|Apabile onda member Syarkat maklumat berkatan orang ain, anda mengesahan bahowa ‘mereka telah melankanda untuk berindak bagi pihok mereka untuk bersecyu dengan pempresesan Data Peribad mereka dan w papa nis data prvas ‘CONSENT TO PROCESS AND DISCLOSE PERSONAL DATA / PERSETUJUAN UNTUK MEMPROSES DAN MENDEDAH DATA PERIBADI Lave fully read and une! 10 this Data Privacy Notice. lhereby confirm that lave exp tuk menerima baa pihak mereka onsent in accordance with the provisions ofthe Personal Data Protection Act 2010, on beral of myself and any famly members, dependants, or other persons (collectively raftred to as “ather persons"), to the Company andjor is Group to colt, use, isclse, transfer, share or atherise process my Personal Date andthe Personal Data of the other persons including sensitive personal data forthe abovementioned purposes. confirm that where Ihave provided Personal Data abou the other persons, as part of lam Ihave obtained the consent ofthe individual(s) concerned to enable the Cornpany andjor its Group to use their Personal Data, including any sense personal data. | also confi that Ihave brought the Daa Privacy Notice tothe attention ofthe other persons whe coir that they understand, agree and authorize the Company andfor its Gecara to Derkongs! atau sebal ‘up to deal with ther Personal Dat ya dryjuksebog ‘orang-orang lan’), kepada yank daatau Kumpulanayo ur tuk mengum mn denge nya menggunakon Data Peibad mereka, termasuk apa-apa dota peribadl sens in accordance with the declaration above. / Soya telah membaca dan memahar sepenuhnyo Notis Data Privasi i. Soya mengesohkan bahawa saya member persetyuan yong nya, mengikutperuntukan Atta Pe ‘mano ah Keluarga,tonggungan, benefiar peregang amanah, indungan Peibadi 2010 baa pihak saya dan mano I perbady, penama, pemegang sera hak atau sesiapa yang dinamakon dalam borang ni nggunakor, mendedahkan memindahkor, nya memgreses Data Penbad saya dan Data Pevbadiorang-orang lin termasuk data peribad)sensif untuk tujuan-tjuan yang dnyatakon

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