1. The takaful company has not been notified of an accident on 14-11-2017 involving vehicles with registration numbers QTN567 and DCY7624. 2. For a claim to be considered, the certificate holder must notify the takaful operator of any incident that may result in a claim. Failure to notify means the certificate holder is responsible for claims. 3. The third party is requested to complete and return an accident claim form along with a police report or statutory declaration and any other requested documents for the takaful company to consider the claim.

1. Your Ref : DCY7624 WITHOUT PREJUDICE
Our Ref 0261714892-001/HOT21
Date: 07-02-2018
AZLINA BINTI GHAZALI
KAMPUNG TO DAP TO UBAN
17050 PASIR MAS
KELANTAN
Dear Sir
ACCIDENT ON 14-11-2017 INVOLVING VEHICLES NO : QTN567 AND DCY7624
The above matter refers.
We would advise that our client has not notified us of the above accident. Please note that under the
conditions of a motor takaful certificate, the certificateholder must notify his takaful operator of any
incident, which he is aware, may result in a claim against his certificate. A takaful operator can only
accept liability on behalf of its certificateholder if the takaful operator has received a notification from
its certificateholder to take over the conduct of a claim. In the event of a certificateholder does not
notify his takaful company, the certificateholder himself is responsible for any claims arising from an
accident involving third party property damage. We would advise that the repudiation of liability by a
takaful operator as a result of non-reporting or unreasonably late reporting of accidents by the
certificateholder is in accordance with the conditions of the takaful contract between the takaful
operator and the certificateholder. Legally, the third party can only take action against the person
causing the damage and not the takaful company.
However, without admission of liability, we enclose our Third Party Motor Vehicle Accident Form
which you are required to complete in full, sign and return to us together with the following documents
for our consideration:-
A) If our certificateholder’s police report is not available, a Statutory Declaration by you declaring the
circumstances of the accident and identifying our certificateholder’s vehicle as a party to the
accident.
Kindly revert with the documents requested to enable us to consider your claim further.
Yours faithfully,
ZURICH TAKAFUL MALAYSIA BERHAD
NORSANIAH BINTI SATAR,
EXECUTIVE - GENERAL CLAIMS
Tel: 03-21469120
Email: norsaniah.satar@zurich.com.my
THIS IS A COMPUTER GENERATED DOCUMENT. NO SIGNATURE IS REQUIRED.

2. THIRD PARTY MOTOR VEHICLE ACCIDENT CLAIM FORM
Important: It is compulsory to fill up all details truthfully below for us to entertain your claim.
1. THE OWNER
Name: Mr/Mrs/Ms/Mdm:_______________________________________________________
Identity Card No.(New):________(Old)__________or Business Registration No: __________
Home Address: __________________________________________Post Code:____________
Office Address: __________________________________________Post Code:____________
Business or Occupation:_________________Phone No. Office:________House:___________
Certificate No:___________Expiry Date:__________
Comprehensive Third Party
2. THE DRIVER
Name: Mr/Mrs/Ms/Mdm:________________________________________________________
Identity Card No(New):________________________(Old):______________________
Address_______________________________________________Post Code:______________
Age:_______Occupation:______________________Relationship to Participant:______________
Was he Driving with your permission? Yes No
Driving Licence No.:__________________________Expiry date of licence:________________
Is it a Full or Provisional Licence?___________________Class(es) covered:________________
Driver’s Driving Experience:________years experience. Date driving test passed:___________
Has the Driver ever been convicted of an offence in connection with the driving of a Motor
Vehicle?
If so, give brief details and date(s)__________________________________________________
Has Driver previously been involved in an Accident?___________________________________
If Paid Driver, how long has he been in your employment?_______________________________
3. THE VEHICLE
Make and Model:_______________Year of Manufacture:_______Reg.No.:_________________
Was a Trailer attached?__________Vehicle Log Book No.:______________________________
For what purpose was the vehicle being used?_________________________________________
4. THE ACCIDENT
Date of Accident:________/________19_________Time:_________am/pm
Place of Accident:_______________________________________________________________
At what speed was your vehicle traveling at the time of accident?__________________________
Were you in the vehicle?________If not when was the accident reported to you?______________
Claim Number: 0261714892-001/HOT21

3. Explain exactly how the accident occurred(Please do not write “Refer to the Police Report”)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
PLAN OF ACCIDENT
PLEASE INDICATE AS CLEARLY AS POSSIBLE APPROXIMATE WIDTH OF ALL ROADS IN
THE VINCINITY OF THE ACCIDENT AS WELL AS THE POSITION, AND BY MEANS OF
ARROWS, THE DIRECTION OF PROGRESS OF ALL VEHICLES AND PERSONS INVOLVED.
BEFORE AFTER
5. POLICE
Police station to which report of accident was made_____________________________________
Report No.:_____________________________________________________________________
Have you received notice of intended prosecution or summons?___________________________
If so, what is the nature of the offence?_______________________________________________
6. WITNESSES
State names and addresses of witnesses of the accident.
(a) Passengers in your vehicle:_____________________________________________________
(b) Passers by:_______________________________________________________________
(c) Police personnel:___________________________________________________________
7. DAMAGE TO YOUR VEHICLE
Give full details of damage to your vehicle:___________________________________________
_____________________________________________________________________________
Name and address of repairer:_____________________________________________________
_____________________________________________________Telephone No.:__________
Claim Number: 0261714892-001/HOT21

4. 8. DETAILS OF OTHER VEHICLES INVOLVED IN THE ACCIDENT.
State name and address of owners of other vehicles involved in the accident:-
(i) Registration No. of the vehicle:____________Name of Driver:_________________
(ii) Name of Owner: ______________________Address:________________________
(iii)Name of takaful Company and Certificate or Policy No.:____________________
_____________________________________________________________________
(b) State names, address of every person injured, their age and nature of injuries:-
(i) In your vehicle:-
Name Age Address Nature of Injuries
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
(ii) In other vehicle:-
Name Age Address Nature of Injuries
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
(c) Was the injured person(s) warded or treated as outpatient?________________________
(d) State name and address of hospital/clinic:______________________________________
(e) Give details of vehicle or other property damaged (other than own vehicle):___________
_______________________________________________________________________
(f) Has any claim been made against you for (I) personal injury or (ii) damage to property? If
(g) so, state names and addresses of claimants and give full particulars of claim(s).
(i) Personal injury:___________________________________________________________
________________________________________________________________________
(ii) Damage to property:________________________________________________________
________________________________________________________________________
9. RESPONSIBILITY OF THE ACCIDENT
Whom do you consider was responsible for the accident? Why?___________________________
_____________________________________________________________________________
If the accident was due to the negligence of any other person(s), give their name(s), address(es)
and vehicle number(s):
_____________________________________________________________________________
_____________________________________________________________________________
Was the responsibility admitted by either party?________________________________________
Has the police taken action against the driver? If yes give details:__________________________
_____________________________________________________________________________
_____________________________________________________________________________
I/We hereby declare the foregoing particulars are true in every respect and that I/We have no other
insurance indemnifying me/us in respect of this accident. I/We also agree that if I/We have made any
false or fraudulent statement or any suppression or concealment, the claim shall be void in respect of
the said accident.
Signature of Owner:_______________________ Date:____________
I.C. No.: ________________________________
Signature of Driver:________________________ Date:____________
I.C. No.:_________________________________