Slide 1

SPEEDY CLAIMS PROCESSING

COMPLETE PEACE OF
MIND WHEN YOU CLAIM

Motor Claim

IMPORTANT STATEMENT - You are to disclose in this claim form, fully and faithfully all the facts which you know or ought to know, otherwise the claims issued hereunder may be invalidated.

Policy
Verification

Personal
Information

Claim
Selection

Claim
Information

Document
Upload

Claim
Summary

Claim
Submission

PLEASE ENTER THE FOLLOWING DETAILS FOR VERIFICATION PURPOSES:

POLICY NUMBER *

VEHICLE REGISTRATION NUMBER *

I/We agree to disclose in this claim form to National Insurance Company Berhad, fully and faithfully all the facts which I/we know or ought to know, otherwise the claims issued hereunder may be invalidated.

POLICY NUMBER

POLICY HOLDER NAME

IC OR PASSPORT NO.

VEHICLE REGISTRATION NO.

CONTACT NUMBER *

EMAIL ADDRESS *

PLEASE MAKE YOUR CLAIM SELECTION, BELOW:

THEFT CLAIM

WINDSCREEN CLAIM

ACCIDENT CLAIM

FIRE CLAIM

PLEASE REVIEW THE LIST OF DOCUMENTS THAT YOU ARE REQUIRED TO PREPARE FOR UPLOAD, FOR THIS CLAIM

WAS THE POLICY HOLDER DRIVING THE VEHICLE AT THE TIME OF THE ACCIDENT?

Yes

WAS THE VEHICLE PARKED AT THE TIME OF INCIDENT?

Yes

DRIVER NAME *

DRIVER CONTACT NUMBER *

DRIVER CONTACT EMAIL

DATE OF ACCIDENT (DD/MM/YYYY) *

TIME OF ACCIDENT (24HR FORMAT) *

PLACE WHERE THE ACCIDENT/THEFT OCCURED *

DETAILS OF THE EXACT LOCATION *

SPEED OF THE VEHICLE (IN KM/HOUR)

ENTER A BRIEF DESCRIPTION OF HOW AND WHERE THE ACCIDENT OCCURED? *

Characters: 0/2000

WINDSCREEN DAMAGE INFORMATION *

FRONT WINDSCREEN

REAR WINDSCREEN

FRONT DRIVER WINDOW

FRONT PASSENGER WINDOW

REAR LEFT PASSENGER WINDOW

REAR RIGHT PASSENGER WINDOW

HAVE YOU ALREADY PAID THE WORKSHOP *

Yes, If YES, please upload copies of the workshop repair receipts as well as the post repair photos, under the ‘Upload Documents’ section on the next page.

IF YOU WISH FOR PAYMENT TO BE MADE TO YOU VIA ONLINE TRANSFER, KINDLY PROVIDE US WITH YOUR BANK ACCOUNT DETAILS AS FOLLOWS:

BENEFICIARY BANK NAME *

OTHER BENEFICIARY BANK NAME *

BENEFICIARY NAME *

BENEFICIARY BANK ACCOUNT NUMBER *

BENEFICIARY ADDRESS *

BENEFICIARY BANK SWIFT CODE *

ARE YOU CLAIMING FOR YOUR OWN DAMAGE? *

Yes

SELECT THE WORKSHOP WHERE YOU HAVE REPAIRED, OR INTEND TO REPAIR YOUR WINDSCREEN? *

NAME OF THE WORKSHOP *

WAS THERE ANY TYPE OF TRAILER ATTACHED TO THE VEHICLE AT THE TIME OF THE ACCIDENT? *

Yes

TRAILER REGISTRATION NO./PERMIT NO. *

WAS ANYONE INJURED IN THE ACCIDENT? *

Yes

HAS THE ACCIDENT/THEFT BEEN REPORTED TO THE POLICE? *

Yes

WAS THERE ANY THIRD-PARTY VEHICLE DAMAGES? *

Yes

MOTOR VEHICLE REGISTRATION NUMBER *

INSURANCE COMPANY NAME *

ADD MORE

WAS THERE ANY DAMAGE TO ANY THIRD-PARTY GOVERNMENT PROPERTY? *

Yes

WAS THERE ANY DAMAGE TO ANY THIRD-PARTY PRIVATE PROPERTY? *

Yes

								PLEASE UPLOAD YOUR FILES, WHICH SHOULD BE IN EITHER JPG, PNG OR PDF FORMAT. EACH INDIVIDUAL FILE SIZE SHOULD NOT EXCEED 3MB.
								
ALL DOCUMENTS MARKED WITH * ARE MANDATORY

UPLOAD DOCUMENT (POLICY HOLDER'S IC FRONT & BACK) *

UPLOAD DOCUMENT (POLICY HOLDER DRIVING LICENSE) *

UPLOAD DOCUMENT (DRIVER'S IC FRONT & BACK) *

UPLOAD DOCUMENT (DRIVER'S DRIVING LICENSE) *

UPLOAD DOCUMENT (CAR REGISTRATION CARD) *

UPLOAD DOCUMENT (WORKSHOP REPAIR & RECEIPTS) *

UPLOAD DOCUMENT (PHOTOS AFTER WORKSHOP REPAIR) *

UPLOAD DOCUMENT (COMPANY REGISTRATION) *

UPLOAD DOCUMENT (DRIVER AUTHORISATION LETTER) *

UPLOAD DOCUMENT (ROAD TAX) *

UPLOAD DOCUMENT (BRUNEI PASS/MALAYSIA PASS) *

UPLOAD DOCUMENT (POLICE REPORT FOR ACCIDENT/INCIDENT) *

UPLOAD DOCUMENT (THIRD PARTY MOTOR CAR DAMAGE) *

UPLOAD DOCUMENT (THIRD PARTY PRIVATE PROPERTY DAMAGE) *

UPLOAD DOCUMENT (THIRD PARTY GOVERNMENT PROPERTY DAMAGE) *

UPLOAD DOCUMENT (PHOTO OF INCIDENT) *

UPLOAD DOCUMENT (PHOTO OF DAMAGES) *

UPLOAD DOCUMENT (SKETCH OF THE INCIDENT) *

UPLOAD DOCUMENT (OTHER RELEVANT DOCUMENTS)

							PLEASE REVIEW YOUR MOTOR CLAIM SUBMISSION, BELOW.
							IF YOU WISH TO MAKE ANY AMENDMENTS, PLEASE CLICK 'CHANGE' TO MAKE THE NECESSARY CHANGES, THEN RE-SUBMIT.
							

Declaration

Please note that you are submitting this claim to National Insurance Company Berhad. Please see our full Terms of Conditions and Privacy Policy.

By submitting this claim to us, you are deemed to have agreed to us collecting, using, disclosing and processing your personal data for the purpose of assessing your claim. This may include disclosing and sharing your personal data with our service providers and/or with other insurers in the general insurance industry, including BDCB, for the proper processing, handling and/or dealing with your claim, which includes investigating the said claim and complying with applicable laws (collectively, 'the Purpose'). We may also need to disclose or share your personal data with service providers who are sited outside Brunei for the Purpose.

I declare that the information given is true and correct to the best of my knowledge and belief. I understand that any false or fraudulent statements or any attempt to suppress or conceal any material facts shall render the policy void and National Insurance Company may refuse to pay the claim.

Claim for the theft of your vehicle or the vehicle accessories.

Claim for the cost of your windscreen replacement or repair.

Claim for a motor vehicle accident, where your motor vehicle is involved in a collision with other motor vehicles, pedestrians, animals or stationary objects.

Claim for loss or damage to your vehicle, caused by fire.

Comprehensive Coverage

Car rental coverage

MotorCycle Coverage

Third Party Coverage

Claim submission is in-progress.

PLEASE ENSURE THAT FOLLOWING DOCUMENTS IN EITHER JPG, PNG OR PDF FORMAT ARE PREPARED & READY TO BE SUBMITTED AS PART OF YOUR ONLINE CLAIM SUBMISSION. EACH INDIVIDUAL FILE SIZE SHOULD NOT EXCEED 3MB.

Copy of IC (driver and/or owner)
Copy of Driving License (driver and/or owner)
Copy of Car Registration book or Blue-card
Copy of Police Reports (if any)
Photos of of the accident and the sketch of the accident
Copy of Brunei Pass/Malaysia Pass (if any)
And any relevant documents relating to your respective claim submission