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Insurance Claims

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 :
Type of Repair Needed :
Comments :
(*) is compulsory.