06/10/2021, 08:59 Claim Form

ALLIANZ GENERAL INSURANCE COMPANY (MALAYSIA) BERHAD (200601015674)(735426-V)

MOTOR ACCIDENT REPORT FORM

IMPORTANT CONTACT DETAILS:-
INSURED'S MOBILE NO:- DRIVER'S MOBILE NO:-
INSURED'S EMAIL ADDRESS:- DRIVER'S EMAIL ADDRESS:-
FOR OFFICE USE ONLY
Adjuster Date
This claim form is issued to Appointed
(name of agent/broker/policyholder) Notified By Date Notified
Cause of Loss Relationship
By:
Amount Claim Claim No
(name of staff) (HQ/Branch concerned)
Code Reserve Code Reserve
Authorised Signatory:

Date:

IMPORTANT:
It is important that this form is fully completed, duly signed and returned together with the required documents as soon as possible but not later than 14 days
from the date of receipt of this form. This form is issued on a without prejudice basis and not an admission of liability on the part of the company.
TYPE OF CLAIM
Please tick (✔) where applicable
A) Own Damage D) Notification - Claiming Against Third Party
B) Theft of Vehicle/Accessories E) Injury to Third Party
C) Windscreen Damage F) Damage to Third Party Property/Vehicle

PARTICULARS OF INSURED
NAME JIKOL BIN SEBIO OCCUPATION/BUSINESS:

ADDRESS KAMPUNG KABATANG KENINGAU, ,

89000 KENINGAU

OFFICE PHONE NO: OFFICE FAX NO: HOUSE PHONE NO:

POLICY/COVER NOTE NO 21VKK0032893-00
PERIOD OF INSURANCE 04/06/2021 - 03/06/2022 TYPE OF COVER: Comp./Third Party

PARTICULARS OF DRIVER
NAME JIKOL BIN SABID AGE: 56 OCCUPATION/BUSINESS:

ADDRESS SOON YEE SDN BHD 22 TMN BIRAWA PO BOX 201, ,

89008 KENINGAU

OFFICE PHONE NO: OFFICE FAX NO: HOUSE PHONE NO:

DRIVING EXPERIENCE (YEARS) Class:

PARTICULARS OF ACCIDENT/THEFT
REGISTRATION NO. SB479E MAKE/MODEL: TOYOTA HILUX 2016 ON
(Trailer No.)
DATE OF ACCIDENT/THEFT : 18/09/2021 TIME: AM/PM
PLACE OF ACCIDENT/THEFT : MILESTONE/ROAD NAME & TOWN:

POLICE STATION : REPORT NO: KENINGAU/000614/21

Head Office :Suite 3A-15, Level 15, Block 3A, Plaza Sentral, Jalan Stesen Sentral 5, Tel: 03-2264 1188 / 2264 0688
Kuala Lumpur Sentral, 50470 Kuala Lumpur. Fax: 03-2264 1199 www.allianz.com.my
Customer Service :Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Tel: 03-2264 0700 Fax: 03-2264 0602 Toll Free: 1-300-88-1028
Kuala Lumpur Sentral, 50470 Kuala Lumpur. Kuala Lumpur Sentral, 50470 Kuala Lumpur.

Sin Aik Bee Auto Centre Sdn Bhd SB479E

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THE DRIVER AT THE TIME OF ACCDENT/THEFT

(If Insured is driving ignore Question 1 & 2)

1) What is your relationship with the Insured?

If a friend, how long have you known the Insured and how often do you use the vehicle?

2) Who gave you permission to use the vehicle?

3) Do you suffer from any physical disability? No / Yes - please describe

4) For what purpose was the vehicle being used at the time of accident?

5) Have you taken any alcohol or drugs prior to the accident? No / Yes

6) Has the vehicle or any vehicle owned by you ever been involved in any motor accident in the past 3 years?
No / Yes If yes: Registration No: Insurance Co: Accdt. Date:

7) Have you ever being charged or suspended by the police or by the Court (in the past 3 years) for any offences?
No / Yes If yes: What is the charge/offence: Date:

8) Has the engine of the vehicle been modified or replaced or converted to enhance or increase the performance
against the manufacturer's specification? No / Yes - please provide details

9) Do you have any witness to the accident? No / Yes - Name and address

10) Have you ever been refused any Motor Insurance? No / Yes If yes - please provide details

11) Have you entered into any agreement for the sale of the vehicle? No / Yes if yes - please provide details:

THE ACCIDENT (Not applicable to theft of vehicle or windscreen damage)

1) What was the weather and road condition?

2) Direction of travel: From to

3) Speed prior to the accident: km/hr

4) Was the police at the scene of accident: No / Yes

5) Have you been charged by the Police? No / Yes - If yes, what is the charge/offence?
(Please extend a copy of the summons to us)

6) Which part of the vehicle is damaged?

7) Was anyone in the vehicle injured? No / Yes - If yes, please provide details

8) Who did you authorise to remove/tow the vehicle from the scene of accident?

9) Name & address of workshop where we can inspect your vehicle?

Sin Aik Bee Auto Centre Sdn Bhd SB479E

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Please draw a sketch showing the scene of accident including name of roads, position of vehicle and direction of
travel with arrows.

BEFORE AFTER
(please mark 'x' at the point of impact)

Full description of the circumstances leading to the accident/theft/windscreen damage:-

Sin Aik Bee Auto Centre Sdn Bhd SB479E

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THEFT OF VEHICLE

1) Is the vehicle locked? No / Yes If no - please clarify

2) Is the vehicle still under Hire Purchase? No / Yes

If yes : Name of Company Tel. No.

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 or Telephone Post Traffic Light Road Divider

Others : ________________________________________________

3) Injury to Third Party, please provide the following information.

Name And Address Vehicle No. Age Nature Of Injuries

I/We declare that the foregoing answers are true and complete and that I/We hold no other policy indemnifying me/us in respect of this claim.

I/We request you to deal on my/our behalf with the third party claims arising herein in accordance with the terms and conditions of the above-mentioned policy
and I/We authorise you and your solicitors on my/our behalf to make such admissions and settlements and give such consents as you may consider necessary
for the disposal of such claims and any litigation arising thereform.

Insured's Signature Driver's Signature

Date : Date :

Sin Aik Bee Auto Centre Sdn Bhd SB479E

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06/10/2021, 08:59 Claim Form

DOCUMENTS CHECKLIST

Please return the MOTOR ACCIDENT REPORT FORM together with the documents (Marked X) under the Type of Claim you are submitting. For an accident
involving F) Injury to Third-party and G) Damage to Third-party property or vehicle, you must complete page 4 of the MOTOR ACCIDENT REPORT FORM.

Type of Claim A B C D E
Own KFK Theft of Windscreen Notification
Documents
Damage Claims Vehicle Damage Only

Police report - original X X X X X

Copy of vehicle's Registration Card X X X X X

Copy of Insured's Identity Card/Passport X X X X X

Copy of Driver's Identity Card/Passport X X X X X

Copy of Driver's Driving License/International
X X X X X
Driving License
Copy of Policy Schedule or Covernote X X X X X

Copy of Roadtax Disc X X X

Copy of Puspakom Disc (Commercial Vehicle) X X X X

Copy of Commercial Transport Permit/License X X X X

Copy of Police Compound/Summons (if any) X X X

Copy of Hire Purchase Agreement X

Workshop's estimate/quotation X X

Repair bill/payment receipt X

Photographs X
Copy of Company's Business Registration
X X X
(for company owned vehicle)
Statutory Declaration From Insured X

JPJ's extract on Third Party's vehicle X

Police Investigation Outcome Report X

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06/10/2021, 08:59 Claim Form

ALLIANZ GENERAL INSURANCE COMPANY (MALAYSIA) BERHAD (200601015674)(735426-V)

DATA PRIVACY NOTICE & CONSENT FORM (DEATH CLAIMS) / BORANG

NOTIS DATA PRIVASI & PERSETUJUAN (TUNTUTAN KEMATIAN)

1. Processing of Your Personal Data / Pemprosesan Data Peribadi Anda

Allianz General Insurance Company(Malaysia) Berhad("Company") will use the information you supply in the Death Claim Form to, among others, process
your claim in accordance with the Personal Data Protection Act 2010, other related legislation, the Company's and/or its Group's own strict internal policy. /
Allianz General Insurance Company(Malaysia) Berhad("Syarikat")akan menggunakan maklumat yang anda bekalkan dalam Borang Tuntutan Kematian
untuk, antaranya, memproses tuntutan anda mengikut Akta Perlindungan Data Peribadi 2010, undang-undang lain yang berkaitan dan polisi dalaman
Syarikat dan/atau Kumpulannya sendiri yang ketat.

The personal information supplied by you will include policy information, financial information and sensitive personal data about you and the deceased which
include information on physical or mental health or medical condition or religious beliefs("Personal Data")./ Maklumat peribadi tersebut, samada yang
dibekalkan oleh anda atau ahli keluarga anda yang lain, akan termasuk maklumat polisi, kewangan dan data peribadi sensitif berkenaan anda dan mana-
mana ahli keluarga anda merangkumi maklumat berkaitan kesihatan fizikal atau mental, keadaan perubatan atau kepercayaan agama, sekiranya mereka
juga dilindungi di bawah insurans yang mana suatu tuntutan dibuat ("Data Peribadi").

The Company may also obtain your Personal Data from other sources, such as bureau or agencies established or to be established by regulatory authorities,
operators of registers or databases available to the insurance industry; other external database suppliers, governmental departments, agencies or authorities;
any party who has, does or will provide products or services to you and to whom you have granted consent, the Company's commercial partners, insurance
intermediaries, reinsurers and third party administrators and/or service providers, other insurance companies, attending doctors, hospitals, clinics, other
medical professionals, facilities or pharmacies, workshops, lawyers and agents that have knowledge of the deceased or records in respect there of or who
had attended to or treated the deceased(as the case maybe), proposed assignees, group policy holders, and related persons or organizations from whom
such information would be essential for the proper processing of the data for the purposes as stated herein./ Syarikat mungkin memperoleh Data Peribadi
anda daripada sumber-sumber lain, seperti biro atau agensi-agensi yang ditubuhkan atau akan ditubuhkan oleh pihak berkuasa kawal selia, operator rekod
atau pangkalan data yang tersedia kepada industri insurans, atau pembekal-pembekal pangkalan data luar, jabatan kerajaan, agensi atau pihak berkuasa,
mana-mana pihak yang telah, sedang atau akan membekalkan produk atau khidmat kepada anda dan kepada siapa yang anda telah memberikan
persetujuan, rakan-rakan komersil Syarikat, pihak perantara insurans, pihak penanggung insurans semula, pengurus dan/atau pembekal perkhidmatan pihak
ketiga, syarikat insurans yang lain, doktor perawat, hospital, klinik, ahli profesional perubatan lain, kemudahan atau farmasi perubatan yang lain, bengkel,
peguam, agen yang mempunyai pengetahuan tentang simati atau rekod yang berkaitan atau sesiapa yang telah memeriksa atau merawati simati(yang mana
berkaitan), pemegang serah hak yang dicadangkan, pemunya polisi berkumpulan; atau orang-orang yang berkaitan atau organisasi daripada mana maklumat
sebegitu adalah penting untuk pemprosesan data yang sepatutnya untuk tujuan yang dinyatakan di sini.

2. Impact resulting from failure to supply information / Akibat daripada kegagalan untuk membekalkan maklumat

You may choose whether or not to provide your Personal Data to the Company. However, failure to supply your Personal Data as requested may result in the
Company being unable to evaluate your claim, which may lead to your claim being denied. Hence, it is obligatory for you to provide the Company your
Personal Data when you choose to make a claim in respect of a policy with the Company./ Anda boleh memilih sama ada hendak memberikan Data Peribadi
anda kepada Syarikat atau tidak. Walau bagaimana pun, kegagalan untuk memberikan Data Peribadi anda seperti yang diminta mungkin akan
mengakibatkan Syarikat tidak dapat menilai tuntutan anda, yang mana boleh menyebabkan tuntutan anda ditolak. Dengan itu, adalah menjadi obligasi anda
untuk membekalkan kepada Syarikat Data Peribadi anda apabila anda memilih untuk membuat tuntutan terhadap polisi dengan Syarikat.

For the purposes of evaluating and administering claims, the Company may also rely on this authorization to disclose information about the deceased to the
authorized third parties so that they may conduct health care operations, claims payment, administrative and audit functions related to the deceased's benefit
plans, if any./ Bagi tujuan penilaian dan pentadbiran tuntutan, Syarikat juga boleh bergantung kepada persetujuan ini untuk mendedahkan maklumat
berkenaan simati kepada pihak ketiga yang diberikuasa supaya mereka dapat melakukan operasi kesihatan, bayaran tuntutan, pentadbiran dan fungsi audit
berkaitan dengan manfaat si mati, jika ada.

3. Purposes of Collecting and Using Your Personal Data / Tujuan Mengumpul dan Menggunakan Data Peribadi Anda

Your and the deceased's Personal Data will be collected, used and otherwise processed by the Company for the following purposes: / Data Peribadi anda
akan dikumpul, diguna dan sebaliknya diproses oleh Syarikat untuk tujuan-tujuan berikut:
(a) for claims processing, evaluation, administration and claim settlement; / untuk memproses tuntutan, menilai, mentadbir dan penyelesaian tuntutan;
(b) for detection and prevention of criminal activity or fraud in connection with an insurance transaction and/or improper claim; / untuk mengesan dan
mengelakkan aktiviti jenayah atau penipuan berkaitan dengan transaksi insurans dan/atau tuntutan tidak betul;
(c) to ensure that the Company's records are updated; / untuk memastikan bahawa rekod Syarikat adalah terkini;
(d) for statistical analysis and surveys; / untuk analisis statistik dan kaji selidik;
(e) for data transfer to,and sharing with, other members of the Group and / or third parties acting on behalf of the Company, including those located outside
Malaysia. / untuk pemindahan data kepada, dan berkongsi dengan, ahli-ahli lain dalam Kumpulan dan/atau pihak ketiga yang bertindak bagi pihak
Syarikat, termasuk yang berada di luar Malaysia.

4. Disclosure of Your Personal Data / Pendedahan Data Peribadi Anda

Your and the deceased's Personal Data may also be disclosed to authorized third parties including other insurers, brokers, credit organizations, underwriters,
reinsurers, group policyholders, benefit plan administrators, those to whom the Company outsource certain business operations, the Company's commercial
partners, regulatory authorities, bureau or agencies established or to be established by regulatory authorities, operators of registers or databases available to
the insurance industry, loss adjusters, lawyers, auditors, persons conducting actuarial or research studies, accountants, consultants, surveyors, external
claims data collectors, investigators and medical professionals, and any other contractors or sub-contractors as required or permitted by law or as we may
determine to be necessary or appropriate. / Data Peribadi anda dan simati juga boleh didedahkan kepada pihak ketiga yang diberi kuasa termasuk syarikat
insurans yang lain, broker, organisasi-organisasi kredit, pengunderait, pihak penanggung insurans semula, pemunya polisi berkumpulan, pihak pengurusan
pelan manfaat, kepada mereka yang mana Syarikat telah menyumber luar operasi bisnes yang tertentu, rakan-rakan komersil Syarikat, pihak berkuasa kawal
selia,biro atau agensi yang telah atau akan ditubuhkan oleh pihak berkuasa kawal selia, operator rekod atau pangkalan data yang tersedia kepada industri
insurans, penyelaras kerugian, peguam, juruaudit, mereka yang melaksanakan penyelidikan aktuari atau kaji selidik, akauntan, pakar runding, peninjau,
pengumpul data tuntutan luar, penyiasat dan profesional perubatan dan mana-mana kontraktor atau sub-kontraktor lain yang diperlukan atau dibenarkan oleh
undang-undang atau yang diputuskan oleh kami sebagai perlu atau bersesuaian.

5. Your Rights of Access to Your Personal Data / Hak Anda Untuk Akses Kepada Data Peribadi Anda

You have the right to 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 Officer at 1300-88-1028 from 8.45 a.m. to 5.45 p.m., Monday to Friday or email at [email protected] or via our Fax No. 03-
2264 8499. You also have the right to request in writing for the Company to cease processing your Personal Data. / Anda berhak untuk meminta secara
bertulis akses kepada, membuat apa-apa pertanyaan atau aduan berkaitan dengan Data Peribadi anda yang disimpan oleh Syarikat dengan menghubungi
Pegawai Perkhidmatan Pelanggan Syarikat di 1300-88-1028, dari 8.45 pagi hingga 5.45 petang, Isnin hingga Jumaat atau emel kepada
[email protected] atau melalui No. Faks 03-22648499. Anda juga boleh meminta secara bertulis kepada Syarikat untuk berhenti memproses
Data Peribadi anda.

6. Information About Another Person / Maklumat Berkaitan Orang Lain

When you give the Company, information about another person, you confirm that they have appointed you to act for them, to consent to the processing of
their personal data and to receive on their behalf, any data privacy notices. / Apabila anda memberi Syarikat maklumat berkaitan orang lain, anda
mengesahkan bahawa mereka telah melantik anda untuk bertindak bagi pihak mereka untuk bersetuju dengan pemprosesan Data Peribadi mereka dan
untuk menerima bagi pihak mereka apa-apa notis data privasi.

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CONSENT TO PROCESS AND DISCLOSE PERSONAL DATA / PERSETUJUAN UNTUK MEMPROSES DAN MENDEDAH DATA PERIBADI

I have fully read and understood this Data Privacy Notice. I hereby confirm that I give explicit consent, in accordance with the provisions of the Personal Data
Protection Act 2010, on behalf of myself and any family members, dependants, or other persons (collectively referred to as "other persons"), to the Company
and/or its Group to collect, use, disclose, transfer, share or otherwise process my Personal Data and the Personal Data of the other persons including sensitive
personal data for the abovementioned purposes. I confirm that where I have provided Personal Data about the other persons, as part of my claim, I have
obtained the consent of the individual(s) concerned to enable the Company and/or its Group to use their Personal Data, including any sensitive personal data. I
also confirm that I have brought the Data Privacy Notice to the attention of the other persons who confirm that they understand, agree and authorize the
Company and/or its Group to deal with their Personal Data in accordance with the declaration above. / Saya telah membaca dan memahami sepenuhnya Notis
Data Privasi ini. Saya mengesahkan bahawa saya memberi persetujuan yang nyata, mengikut peruntukan Akta Perlindungan Peribadi 2010 bagi pihak saya dan
mana-mana ahli keluarga, tanggungan, benefisiari, pemegang amanah, wakil peribadi, penama, pemegang serah hak atau sesiapa yang dinamakan dalam
borang ini (secara kolektifnya di rujuk sebagai "orang-orang lain"), kepada Syarikat dan/atau Kumpulannya untuk mengumpul, menggunakan, mendedahkan,
memindahkan, berkongsi atau sebaliknya memproses Data Peribadi saya dan Data Peribadi orang-orang lain termasuk data peribadi sensitif untuk tujuan-tujuan
yang dinyatakan di atas. Saya mengesahkan bahawa di mana saya telah memberikan Data Peribadi berkenaan dengan orang-orang lain, saya telah
memperoleh persetujuan individu yang berkaitan untuk membolehkan Syarikat dan/atau Kumpulannya menggunakan Data Peribadi mereka, termasuk apa-apa
data peribadi sensitif. Saya juga mengesahkan bahawa saya telah membawa Notis Data Privasi ini kepada perhatian orang-orang lain yang telah mengesahkan
bahawa mereka memahami, bersetuju dan memberi kuasa kepada Syarikat dan/atau Kumpulannya untuk berurus dengan Data Peribadi mereka mengikut
deklarasi di atas.

Signature / Tandatangan Date / Tarikh

Full Name / Nama Penuh :

NRIC No. / No. Kad Pengenalan :

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