Insurer Offer Letter/DV Page 1 of 2

AXA Affin General Insurance Berhad

(197501002042)
Ground Floor, Wisma Boustead
No 71 Jalan Raja Chulan 50200 Kuala Lumpur
O (603) 2170 8282
F (603) 2031 7282
E customer.service@axa.com.my
www.axa.com.my

Your Reference : AKP 5124

Our Reference : M0M04D9Q
Date : 16-Mar -2020
POTCHSELVI A/P NARASIMMALU
NO 42 INDIAN CAMP
MALIM NAWAR
31700 Malim Nawar
Perak Darul Ridzuan
WITHOUT PREJUDICE

Dear Sir/Madam

ACCIDENT INVOLVING VEHICLE NO. AKP5124 AND ADM7008 ON 05/02/2020

We have reviewed all your claim documents on the above and are prepared to offer a sum of RM400.00 in full and final
settlement of your claim on a without admission of liability basis.

Our breakdown of offer is as follows:

CART (10.0 days x RM40.00/day) : RM 400.00
400.00
Nett Liability : RM
In order for us to proceed with payment, please
1. confirm acceptance by returning the enclosed discharge voucher duly signed for our issuance of payment and
2. complete the following details and attach copy of front page of your latest bank statement (top portion with
bank account details) in order for us to credit the claim payment into your bank account as per Bank Negara
Malaysia's e-payment directive.

Name of Bank

Account Name

Account No

Your e-mail address

We will effect settlement upon receipt of item 1 and 2 above. Yours
faithfully,

ZANARIAH BINTI IDRIS

Executive - Third Party Claim - TP UL Claims

*Compensation for Assessed Repair Time (CART)

Please note that Assessed Repair Time means the number of days required for the repair of the damaged vehicle as assessed
and recommended by the independent loss adjuster and shall exclude any delays,
AXA Affin General Insurance Berhad (197501002042) - Ground Floor, Wisma Boustead, No 71 Jalan Raja Chulan, 50200 Kuala howsoever
and/or by whomsoever caused, which may occur before an/or after the actual repair.
Lumpur
Telephone : (603) 2170 8282 - Fax: (603) 2031 7282 - Email: customer.service@axa.com.my - www.axa.com.my - Service Tax Reg.
No.:W10-1808-31015017

https://www.merimen.com.my/claims/index.cfm?fusebox=SVCdoc&fuseaction=dsp_vie... 4/7/2020
Insurer Offer Letter/DV Page 2 of 2

AXA Affin General Insurance Berhad

(197501002042)
Ground Floor, Wisma Boustead

O (603) 2170 8282

F (603) 2031 7282
E customer.service@axa.com.my
www.axa.com.my
Service Tax Reg. No.:W10-1808-31015017

Reference No: M0M04D9Q

DISCHARGE VOUCHER

I/We POTCHSELVI A/P NARASIMMALU, NRIC/Co. No. 741207-08-6330 acknowledge receipt from AXA Affin General
Insurance Berhad the sum of Ringgit Malaysia Four Hundred only (RM400.00) in full, final and complete satisfaction and
discharge of all claims in respect of damages and loss whether now or thereafter arising directly or indirectly from the
accident which occurred on or about 05/02/2020 involving motor vehicles no. ADM7008 and AKP5124.

I/We recognize that the above payment is an amicable arrangement without in any way constituting any admission of
liability whatsoever and howsoever by AXA Affin General Insurance Berhad and/or the owner/driver of motor vehicle no.
ADM7008.

I/We declare that in consequence of the said payment, I/we or any person or agent appointed have no further claim
whatsoever against AXA Affin General Insurance Berhad and /or the owner /driver of the said motor vehicle number
ADM7008 in respect of the said accident and I/we hereby give full and final discharge.

Dated this 07 day of 04 2020

Signature/Thumb Print of
POTCHSELVI A/P NARASIMMALU
NRIC/Co. No : 741207-08-6330

Witness's Signature

Name :
I/C No

Address
:

:
AXA Affin General Insurance Berhad (197501002042) - Ground Floor, Wisma Boustead, No 71 Jalan Raja Chulan, 50200 Kuala Lumpur
Telephone : (603) 2170 8282 - Fax: (603) 2031 7282 - Email: customer.service@axa.com.my - www.axa.com.my - Service Tax Reg.
No.:W10-1808-31015017

https://www.merimen.com.my/claims/index.cfm?fusebox=SVCdoc&fuseaction=dsp_vie... 4/7/2020