E-FILE

MVMG18016495 / Vermogen Ace Pte Ltd - HQ ENTRY DATE & TIME: 02/02/2018 14:38 SUBMITTED BY: Chong Hao Ling
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 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

02/02/2018 14:38

Date Of Accident

02/02/2018 08:10

Exact Location Of Accident

CHOA CHU KANG DR

Country/State of Loss

Singapore

DETAILS OF OWN VEHICLE

Vehicle Registration Number

SLE3963H

Insured/Policyholder

Name Of Registered Owner

LCRF PTE LTD

Co Reg No

201624597K

Email Address

NOEMAIL

Mobile Phone No

Alternative Phone No

Office-66944919

Vehicle Particulars

Manufacturer

HONDA

Model

VEZEL

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?

If No, Please state action to be taken

Third Party

Vehicle Category

Private Car

Insurance Company

Name of Insurance Company

AIG Asia Pacific Insurance Pte. Ltd.

Type Of Coverage

Comprehensive

Fleet Policy

Yes

Policy Number

999995062

Cover Note Number

Driver

Name of Driver

TAN QING RUI

NRIC No

S8910301J

Date Of Birth

27/03/1989

Occupation

Outdoor

Date Of Driving Pass

11/01/2010

Driving Experience

8 Years And 0 Months

Gender

Male

Mobile Number

Fax Number

Contact Number

EMail Address

NOEMAIL

Address

44 BENOI ROAD BLOCK B (ENTRANCE 6 BENOI SECTOR)

Postcode

Was driver an employee of the Insured's Company

If No, Relationship of the Driver with the Insured

Other - HIRER

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?

Number of vehicles involved in the accident

Was any body injured in the Accident?

Was any injured conveyed to hospital by ambulance?

Was any other material or property damaged?

Yes

I have been approached by unknown person(s) soliciting/offering accident claims assistance.

Number of Passengers (Including Driver)

Passenger 1

Name:	:	UNKNOWN
Gender:	:	Female

Details of Police Action

Was the accident reported to the police?

If Yes,Please state which Police Station

Was notice of intended Prosecution given?

If Yes,against whom?

Circumstances of Accident

PLEASE REFER TO PHOTOS AND VIDEO. THANK YOU.

Attachment(s)

Are accident photos available for attachment?

Yes

Was there any video captured by Car Camera?

Yes

Was there any audio recorded?

DETAILS OF OTHER VEHICLE PROPERTY 1

Vehicle Registration Number

SDA2389M

Vehicle Make/Model/Colour

Details Of Properties

VEH B

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)