Third Party Express Settlement – Payment Breakdown
| NOTE: TO BE COMPLETED BY SURVEYOR |
TEAM _________ |
| THIRD PARTY EXPRESS SETTLEMENT |
| (PAYMENT BREAKDOWN) |
| |
| Vehicle No: |
GBG5680T (Insd veh) |
Model: |
HYUNDAI I40 1.7 L CRDI AT ABS AIRBAG 4DR (A) |
| |
| |
SHB4948J (TP veh) |
| |
| Date of Accident: |
28/11/2019 |
| |
| |
| |
|
| Global Sum Settlement |
: |
[ |
X |
] |
Yes |
[ |
|
] |
No |
|
| |
|
| Repair Estimate |
: $ |
|
|
| |
|
| Final Repair Cost |
: $ |
2,450.00 |
|
| |
| Loss of Use |
: $ |
|
4.00 |
days at $50.00 per day |
| |
| Rental (if any) |
: $ |
|
4 |
days |
| |
| LTA / GIA Search Fee |
: $ |
|
|
| |
| Others: |
: $ |
|
|
| |
| |
: $ |
|
|
| |
|
| Final Settlement Sum (Global Sum) |
: $ |
2,450.00 |
|
| |
| Is Third Party Workshop GIA Registered? [ X ] YES [ ] NO (Kindly indicate below) |
| |
| A) |
For Non GIA Registered Workshop: |
Agreed Liability ___________(%) |
| |
| B) |
For GIA Registered Workshop: |
BOLA Applicable: Yes/ No BOLA Scenario No: __27__ |
| |
BOLA Liability: _____100_____(%) |
Assessed Liability (*):____________(%) |
| |
* Assessed Liability to be filled only for chain collisions and for cases where BOLA does not apply. |
| |
| Payment Instruction: Payee's Breakdown |
| |
| 1) |
ComfortDelGro Engineering Pte Ltd |
: $ |
2,450.00 |
| |
| 2) |
|
: $ |
|
| |
| 3) |
|
: $ |
|
| |
| 4) |
|
: $ |
|
| |
| |
JOANNE LEE KHANG MIN
|
|
08 Apr 2020
|
|
| |
LKK Auto Consultants Pte Ltd |
|
Date |
|
Please attach all the supporting documents to the form.
(Final Repair Bill; Rental Invoice; Release Voucher; Authorisation to Act; Survey Report; Medical Report/ Bill (if any) |