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
Email Mobile No.
GST Registration No.
(If not insured)
with the Insured
Email Mobile No.
* Driving License Number of the person driving the car at time of accident: ________________________________________________
B. VEHICLE DETAILS
Model Registration No.
C. LOSS DETAILS
Date (DD MM YY) Time Location
of Loss/ Damage
□ Own Damage □ Own Damage/ Knock for Knock □ Windscreen Damage
□ Theft □ Notification only
□ Yes □ No
Police Report Lodged?
□ Yes (Report No.: ) □ No
of Loss/ Accident
*If space is insufficient,
please give details in a
* 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.
(as per bank account)
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: _________________________________________________________
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 firstname.lastname@example.org
NRIC/ Passport/ Birth. Cert. No:
Name of Insured:
Signature of Insured: