Fillable Motor Insurance Claim Form

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Motor Insurance Claim Form

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The Motor Insurance Claim Form form is 3 pages long and contains:

  • 0 signatures
  • 28 check-boxes
  • 46 other fields

Country of origin: OTHERS
File type: PDF

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1
Motor Insurance Claim Form
To speed up the process, please (1) Complete this form, (2) Prepare the relevant documents listed on page two, and (3) Mail
them to AXA Office as soon as possible. Thank you.
A. INSURED & DRIVER DETAILS
Insured
Full Name
Email Mobile No.
Correspondence
Address
GST Registration No.
(If registered)
Date of
registration
Driver
(If not insured)
Full Name
Relationship
with the Insured
Email Mobile No.
Correspondence
Address
* Driving License Number of the person driving the car at time of accident: ________________________________________________
B. VEHICLE DETAILS
Make
Model Registration No.
C. LOSS DETAILS
Date (DD MM YY) Time Location
Type
of Loss/ Damage
□ Own Damage □ Own Damage/ Knock for Knock □ Windscreen Damage
□ Theft □ Notification only
Anybody Injured?
□ Yes □ No
Police Report Lodged?
□ Yes (Report No.: ) □ No
Description
of Loss/ Accident
*If space is insufficient,
please give details in a
separate paper.
* If accident sustained Bodily Injury or Third Party Property Damaged, please complete the Annexure 1.
D. BANK ACCOUNT DETAILS (if reimbursement claim)
Please provide your bank details for us to accelerate your claims payment process by direct transfer to your bank account.
Name
(as per bank account)
Bank Name
Account No. Bank Branch
* Payment advice will be sent to your email. Please check if your email address is given in Section A.
E. DECLARATION & CUSTOMER’S DATA PRIVACY NOTICE
[Declaration] I/We hereby declare that the above statements and facts are true, copies of documents are identical with the original one, and that
I/We have not withheld from the Company, any information within my/our knowledge connected with the accident.
[Customer’s Data Privacy Notice] AXA Affin General Insurance Berhad is committed to protect the personal data submitted by and collected from
you. For further details, please refer to our “Data Privacy Notice” published in our website.
Date: _____________________ Signature of Insured: _________________________________________________________
Policy No.
To expedite your claim, please (1) complete this form, (2) prepare the relevant documents required in Page Two and (3) submit them to
or to any AXA office as soon as possible. Thank youclaims@axa.com.my
NRIC/ Passport/ Birth. Cert. No:
Name of Insured:
Email:
Signature of Insured:
Date:
✔
DOCUMENTS REQUIRED FOR CLAIM SETTLEMENT
Below is a list of minimum documents required to proceed your claim. In certain circumstances, more information may be required to
substantiate the claim.
Type
of Loss/ Damage
Documents Required
(Please tick against the documents you have submitted.)
Basic for all types
Completed Claim Form
Copy of Insured’s Identity Card
Copy of Insured’s Driving License
Copy of Driver’s Identity Card – if other than the insured
Copy of Driver’s Driving License - if other than the insured
Copy of Updated Registration Card (both sides)
Police Report (Not applicable for Windscreen Damage carried out in AXA’s panel or franchise workshop)
If applicable below:
Own Damage
Scene of Accident Photographs
Copy of policy or cover note
Appendix 1: Bodily Injury or Third Party Property Damage Questionnaire
Own Damage/
Knock for Knock
All Own Damage claim documents plus:
Declaration form duly signed
Copy of third party’s police report
Copy of police investigation result
Copy of police sketch plan and key
Third party’s vehicle policy details or the RIMV search
Theft
Copy of Hire Purchase Agreement
Copy of Approved Permit (for imported vehicles only)
Windscreen Damage
Before and After repair photographs
with date and time stamp (4 angle photos including the windscreen
logo)
Original Invoice for tinting (both old and new) plus photograph showing the tinted film being peeled off
from the damaged glass
AXA is committed to making your motor insurance claim process as easy as possible.
Thank you for insuring with us. We are always glad to be of your service.
3
B. THIRD PARTY PROPERTY DAMAGE
C. DECLARATION
Appendix 1
BODILY INJURY OR THIRD PARTY PROPERTY DAMAGE QUESTIONNAIRE
Please complete this form and submit with the claim form. Thank you.
A. BODILY INJURY
Person Injured
Description of Injury
Name of Hospital
if hospitalized
Name Contact No.
Property Owner
Damaged Property Details
* For motor vehicle please
provide Vehicle Make and No.
Description of Damage
Name Contact No.
Estimated Loss: RM______________________
*If space is insufficient, please give details in a separate paper.
I/We hereby declare that the above statements and facts are true, copies of documents are identical with the original one, and that
I/We have not withheld from the Company, any information within my/our knowledge connected with the accident.
Date: _____________________ Signature of Driver: _____________________________________________________________
Signature of Insured (If not driver): _
________________________________________________
Policy No.
Name of Driver:
NRIC/ Passport/ Birth Cert. No.:
Email:
Signature of Driver:
Signature of Insured (If not Driver):
Date:
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Motor Insurance Claim Form

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Completed 29 May 2021

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