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ONLY FOR MANUAL SUBMISSION PAYMENT DIRECTLY TO POLICYHOLDER Serial No. RHB INSURANCE BERHAD Co. No. 38000-U LEVEL 12 WEST WING THE ICON NO. 1 JALAN 1/68F JALAN TUN RAZAK 55000 KUALA LUMPUR TEL 603-2180 3000 FAX Claims 03-2161 6322 CLAIM FORM - WINDSCREEN Vehicle No. Policy No. Policy Inception Date Windscreen Sum Insured Particulars of Insured / Driver Name of Insured Name of Driver If driver is not the insured Contact No. Relationship Particular of Accident / Loss Date of Loss Cost of Repair Circumstances of Accident Signature of Driver Signature of Policyholder Date Documents checklist Compulsory / Optional Completed Claim Form duly signed/stamped by the Insured and driver Original invoice with breakdown for cost of glass and labor / tinting both old and new Clear photographs showing the damaged windscreen before repair/replacement in the midst of repair/replacement dismantled damaged windscreen after repair/replacement showing the brand logo and photograph of road tax tinted film peeled off from the damaged windscreen if applicable chassis number of the vehicle Copy of updated vehicle registration card Copy of identity card and driving license Copy of driver s identity card and driving license if applicable Authorization letter for payment from Insured E-payment registration form for direct payment to policyholder if applicable. ONLY FOR MANUAL SUBMISSION PAYMENT DIRECTLY TO POLICYHOLDER Serial No* RHB INSURANCE BERHAD Co. No* 38000-U LEVEL 12 WEST WING THE ICON NO.

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