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To get assistance for your insurance claim, please fill this form :
Name :*
Company :
Contact No. (Office) :
Contact No. (Mobile 1) :*
Contact No. (Mobile 2) :
Email :*
Policy Issuer (Perusahaan Asuransi) :
Policy Expiry Date :
Vehicle Type / Model / Year :*
Color :
Type of Assistance Needed :
Melaporkan kecelakaan (proses administrasi klaim)
Menganalisa kerusakan dan estimasi biaya
Jemput mobil untuk diperbaiki (Vehicle pick up)
Penutupan polis asuransi yang baru (Policy Coverage)
Perpanjangan polis asuransi (Policy Renewal)
Lain-lain
Description :
Vehicle Pick up address :
Contact person :
Contact no 1 :
Contact no 2 :
Address 1 :
Address 2 :
Type of Repair Needed :
Paintless Dent removal
Body repair & paint
Both PDR & Body repair-paint
Comments :
(*) is compulsory.
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