| MCAB18005255 / Cheng Auto Bodyworks - HQ ENTRY DATE & TIME: 11/01/2018 12:32 SUBMITTED BY: Lai Wan Sun |
Your NCD will be affected due to late reporting Actual e-Filling Submission Date & Time: 11/01/2018 18:13 |
| SINGAPORE ACCIDENT STATEMENT | |
| IMPORTANT NOTICE | |
| 1. Please report correctly the details of the accident to speed up the claims process. | |
| 2. This Form must be completed by the Policyholder and/or the Authorised Driver. | |
| 3. Information provided must be as truthful and accurate as possible. Any wilful misrepresentation or witholding of material facts may allow insurance companies to repudiate policy ability. | |
| 4. The issue and acceptance of this Form by insurance companies is not an admission of policy liability on the part of the insurance companies. | |
| 5. Any false reporting may be referred to the Police for investigation. | |
| 6. This report will be forwarded by the insurers of the insurers of the GIA Records Management Centre established by the General Insurance Association of Singapore(GIA) for archiving and that copies of this report will for a fee be made available upon application by interested parties. | |
| 7. By the lodgement of this report to the insurers, you hereby consent to the archiving of this report at the centre and to copies of the report being made available aforesaid. |
| ACCIDENT STATEMENT | |
| Date Of Report | 11/01/2018 12:32 |
| Date Of Accident | 09/01/2018 13:50 |
| Exact Location Of Accident | BKE TWDS PIE |
| Country/State of Loss | Singapore |
| DETAILS OF OWN VEHICLE | |
| Vehicle Registration Number | SKQ5196R |
| Insured/Policyholder | |
| Name Of Registered Owner | GOH KENG HAN FRANCIS |
| NRIC No | S7921392F |
| Email Address | NOEMAIL |
| Mobile Phone No | (LOCAL) +65-91914911 |
| Alternative Phone No | Office-91914911 |
| Vehicle Particulars | |
| Manufacturer | PEUGEOT |
| Model | 308-1.6 Turbo Glass Roof (A) |
| Exact Purpose for which vehicle was being used at time of accident | |
| Are you claiming under your own insurance policy for repair to your vehicle? | Yes |
| If No, Please state action to be taken | |
| Vehicle Category | Private Car |
| Insurance Company | |
| Name of Insurance Company | China Taiping Insurance (Singapore) Pte. Ltd. |
| Type Of Coverage | Comprehensive |
| Fleet Policy | No |
| Policy Number | DMPCSN1737761700 |
| Cover Note Number | |
| Driver | |
| Name of Driver | GOH KENG HAN FRANCIS |
| NRIC No | S7921392F |
| Date Of Birth | 26/07/1979 |
| Occupation | Indoor |
| Date Of Driving Pass | 05/08/1999 |
| Driving Experience | 18 Years And 5 Months |
| Gender | Male |
| Mobile Number | (Local) +65-91914911 |
| Fax Number | |
| Contact Number | Office-91914911 |
| EMail Address | NOEMAIL |
| Address | SINGAPORE |
| Postcode | |
| Was driver an employee of the Insured's Company | No |
| If No, Relationship of the Driver with the Insured | Owner |
| Vehicle Registration Number of Driver's Own Vehicle |
- - - |
| Insurance Company of Driver's Own Vehicle |
- - - |
| General Information of the Accident | |
| Type Of Accident | Collision - Head to Rear |
| Weather Conditions | Clear |
| Road Surface | Dry |
| Other Information | |
| Was any foreign vehicle involved in this accident? | No |
| Number of vehicles involved in the accident | |
| Was any body injured in the Accident? | Yes |
| Was any injured conveyed to hospital by ambulance? | Yes |
| Was any other material or property damaged? | Yes |
| I have been approached by unknown person(s) soliciting/offering accident claims assistance. | No |
| Number of Passengers (Including Driver) | 1 |
| Details of Police Action | |
| Was the accident reported to the police? | Yes |
| If Yes,Please state which Police Station | |
| Police Station Name | Jurong West Neighbourhood Police Centre |
| Police Station Address | ROAD: 700 Corporation Road , POSTCODE: 649818 , COUNTRY: Singapore |
| Police Station Contact | TEL NO: 1800-2689999 - FAX NO: 62672438 |
| Was notice of intended Prosecution given? | No |
| If Yes,against whom? | |
| Circumstances of Accident | |
| PLEASE REFER TO POLICE REPORT T/20180110/2066. | |
| Attachment(s) | |
| Are accident photos available for attachment? | Yes |
| Was there any video captured by Car Camera? | No |
| Was there any audio recorded? | No |
| DETAILS OF OTHER VEHICLE PROPERTY 1 | |
| Vehicle Registration Number | SLQ1095M |
| Vehicle Make/Model/Colour | |
| Details Of Properties | |
| Vehicle Category | Private Car |
| Name of Driver | |
| NRIC/Passport Number | |
| Contact Number | |
| Address | |
| Postcode | |
| Insurance Company Name | |
| Nature Of Damage | |
| No. Of Passenger (Including Driver) | |
| DETAILS OF INJURED PERSON 1 | |
| Name | |
| Approximate Age | |
| Injuries Sustain | |
| Injured person in which vehicle? | SLQ1095M |
| Were seat belts worn? | |
| Was this injured conveyed to hospital by ambulance? | Yes |
| Address | |
| Postcode | |