UNDERTAKING & DISCHARGE OF LIABILITY FORM

WRECK PURCHASED FROM AXA AFFIN

DATE :

TO : AXA AFFIN GENERAL INSURANCE BERHAD

GROUND FLR, WISMA BOUSTEAD,
71, JALAN RAJA CHULAN,
50200 KUALA LUMPUR.

VEHICLE NO. :
MAKE & MODEL:

Yong Kok Keong

I/We, __________________________________ (NRIC/ Co. Reg. No.: 830305-05-5167
______________) the wreck buyer
of the above-mentioned vehicle number hereby:

1. Confirm that the repairs to the said motor vehicle have been completed and I/we require the original
Registration Card to arrange for a Puspakom roadworthiness inspection on the repaired vehicle.

2. Agree to submit a copy of the Puspakom inspection report within one month from the date of this
letter to AXA Affin General Insurance Bhd for the release of the transfer of ownership documents.

3. Agree to return the original Registration Card to AXA Affin General Insurance Bhd in the event the
vehicle fails the Puspakom roadworthiness inspection.

4. Take full responsibility for the custody and safekeeping of the original Registration Card whilst it is in
my/our control and custody. If the Registration Card is lost, I/we shall be fully responsible for obtaining
the necessary replacement from Jabatan Pengangkutan Jalan Malaysia (JPJ) at my/our own cost.

5. Fully aware that I/we are responsible to repair this vehicle to a road-worthy condition and agree to
discharge AXA Affin Insurance Berhad from any future claim or liabilities whatsoever arising from the
failure by me/us to have the vehicle inspected or certified as required under the prevailing laws and
regulations.

Yours faithfully,

For (Signature) : Witnessed by (Signature):

Name : Name :
NRIC No. : NRIC No. :
Designation : Designation :
Company Stamp: Address :

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