ááá¶ááï áááááááá¶ááá¶ááï á motor accident ... - Forte Insurance
ááá¶ááï áááááááá¶ááá¶ááï á motor accident ... - Forte Insurance
ááá¶ááï áááááááá¶ááá¶ááï á motor accident ... - Forte Insurance
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
FORTE INSURANCE (CAMBODIA) PLC.<br />
PHNOM PENH SIEM REAP BATTAMBANG<br />
325 Mao Tse Toung Boulevard, Mondol Stat Chas, Phum Salakanseng, No.26, National Road No.5,<br />
Tel: (+855) 23 885 077/066 SangKat Svay Dangkum, Phum Romchek 5, SangKat Rattanak,<br />
Fax: (+855) 023 982 907 Tel: (+855) 063 963 355 Tel: (+855) 053 731 617<br />
Web: www.forteinsurance.com Fax: (+855) 063 963 610 Fax: (+855) 053 731 700<br />
E-mail: info@forteinsurance.com E-mail: srp@forteinsurance.com E-mail: bbp@forteinsurance.com<br />
របាយករ ណ៍េ្រគ ាះថាថររ<br />
MOTOR ACCIDENT CLAIM FORM<br />
1. អគា៍រតវបាន / INSURED<br />
-េឈ្ /Name:………………………………………………………………...<br />
-អសយដ /Address:………………………………………………………<br />
……………………………………………………………………………………..<br />
-មុខរបរ/Occupation:....................................................................<br />
-េលខទូរស័ព/Telephone:…………………………………………………..<br />
-េលខប័ណធានារ៉ប/Policy No:………………………………………..<br />
-ៃថផុតកំណត់/Expiry date:…………………………………………………<br />
-េតអគាមបប័ានានារ៉ប់រងេផ្ស ែដលធានាេលេ្រគ ាះ<br />
ឬ ករបាត់បង់េនះែដរឺ Do you have any other insurance<br />
covering this <strong>accident</strong> or loss<br />
អត់/NO មា/YES សូមប ក់ព័ត៌មា<br />
លំអិតទាះទបបឹបប័ានាន ារ៉ និង្រកមេហ៊ុនធានារ៉/<br />
Please give us the details related to the insurance policy and<br />
the insurance company:……………………………………………………<br />
……………………………………………………………………………………..<br />
2. អគាណបកបរេនណពលណ៍េ្រគ ាះថាថររ / DRIVER AT THE<br />
TIME OF ACCIDENT<br />
-េឈ្ /Name:…………………………………………………………………<br />
-អសយដ /Address:………………………………………………………<br />
……………………………………………………………………………………..<br />
-មុខរបរ/Occupation:....................................................................<br />
3. យបាបរបះអគា៍រតបបាន / VEHICLE OF INSURED<br />
-មា ៉កយានយ/Make and model:………………………………………..<br />
-សា ណ ល ខ /Registration no:……………………………………………….<br />
-ឆគ ំផលពរ/Year of manufacture:………………………………………….<br />
-េលខសក់សុ/Chassis no:…………………………………………………<br />
-េលខមា៉សុី/Engine no:..............................................................<br />
-េលខទូរស័ព/Telephone:…………………………………………………..<br />
-ប័ណេបកបរ/Driving license: មា/YES អត់/NO<br />
-ទំនាក់ទំនងជាាអគា៍រតបបាន / Relation with the insured:<br />
....................................................................................................<br />
-េនេពលមានេ្រគ ាះ<br />
េតរថយន្រតវបានេ្របះាគ ុបណេល<br />
បំណងអ ី For what purpose was the vehicle being used at the<br />
time of <strong>accident</strong>........................................................................<br />
4. អំពីណ៍េ្រគ ាះថាថររ / ACCIDENT<br />
-ៃថ ែខ ឆគ និងេមា ំ ៉ងៃនេ្រគា ះថ/Date and time of <strong>accident</strong>:…….<br />
……………………………………………………………………………………..<br />
-ទីកែបបៃបណ៍េ្រគ ាះថាថររ / Place of <strong>accident</strong>:………………..<br />
……………………………………………………………………………………<br />
……………………………………………………………………………………..<br />
……………………………………………………………………………………..<br />
-េនេពលមានេ្រគ ាះ<br />
េតអគា(អគាណបកបរ)មានពិសរេ្រ<br />
សវឹង ឬណ៍េ្បណេញប ឬស ិតេ្រកមឥ ពពលៃបណ៍េ្រគងសឹប<br />
ណ៍េ្បណេញប រឺេទ At the time of <strong>accident</strong>, were you (driver)<br />
drinking or using drugs or under the influence of alcohol or<br />
drugs មា/YES អត់/NO<br />
-េតអគា(អគាណបកបរ)<br />
ងអគាបបងណេរាគ ុបារី ណ៍េ្រគ ាះណប្ែមន<br />
រ ឺេទ Did you (driver) make this <strong>accident</strong> happen<br />
ឬ<br />
ា 5. ករខូចខតយានយន ផាល់ ប / DAMAGE TO OWN<br />
VEHICLE<br />
-សូមផល់ព័ត៌មានលំអិតអំពីករខូច/Give details of damage:<br />
……………………………………………………………………………………<br />
……………………………………………………………………………………..<br />
-តៃមជួសជុលែដលបា បះិ បអះជដ ុ ល រ / Estimated cost of<br />
repair in USD:…………………………………………………………………<br />
បា/ច/YES<br />
អត់/NO<br />
-េឈ្ យ ប យដ ប/Garage name:………………………………………….
6. ករខូចរយបាបរបះររពាជប / DAMAGE TO<br />
THIRD PARTY VEHICLE<br />
-េឈ្ /Name:…………………………………………………………………<br />
-អសយដ /Address:………………………………………………………<br />
……………………………………………………………………………………..<br />
-េលខទូរស័ព/Telephone:…………………………………………………..<br />
-មា ៉កយានយ/Make and model:………………………………………..<br />
-សា ណ ល ខ /Registration no:……………………………………………….<br />
-ឆគ ំផលពរ/Year of manufacture:………………………………………….<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
9. គំនូស្រព / SKETCHES<br />
មុនេពលេ្រគាះ ថា Before the <strong>accident</strong><br />
-េលខសក់សុ/Chassis no:…………………………………………………<br />
-េលខមា៉សុី/Engine no:..............................................................<br />
-សូមផល់ព័ត៌មានលំអិតអំពីករខូច/Give details of damage:<br />
....................................................................................................<br />
....................................................................................................<br />
-តៃមជួសជុលែដលបា បះិ បអះជដ ុ ល រ / Estimated cost of<br />
repair in USD:…………………………………………………………………<br />
េ្រកយេពលេ្រគ ាះ After the <strong>accident</strong><br />
7. របួសចំេព្អគាែដលពាះព័បឥបឹបណ៍េ្រគ ាះថាថររ /<br />
INJURY TO PERSON(S) INVOLED IN THE ACCIDENT<br />
-េឈ្ /Name:…………………………………………………………………<br />
-អសយដ /Address:………………………………………………………<br />
……………………………………………………………………………………..<br />
-េលខទូរស័ព/Telephone:…………………………………………………..<br />
-សូមផល់ព័ត៌មានលំអិតអំពីរបួ/Give details of injury:……..……<br />
……………………………………………………………………………………..<br />
-េឈ្ /Name:…………………………………………………………………<br />
-អសយដ /Address:………………………………………………………<br />
……………………………………………………………………………………..<br />
-េលខទូរស័ព/Telephone:…………………………………………………..<br />
-សូមផល់ព័ត៌មានលំអិតអំពីរបួ/Give details of injury:…..………<br />
……………………………………………………………………………………..<br />
8. សូមពន្លះលំអពរអំពីណ៍េ្រគ ាះថាថររ / PLEASE<br />
EXPLAIN IN DETAIL HOW THE ACCIDENT HAPPENED<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
ខ ុំ/េយងសូម្របកសថាចំេលយទំងអស់មានភាព្រ និងេពញេលញ<br />
។ I/We declare that all the answers are true and complete.<br />
ខ ុំ/េយងសូមណគ សុំេអ ្រកមេហ៊ុនធានារ៉ហតេតណយ្ិាងមាយ<br />
តតិយជបាគ ុងនមខ ុំ/េយង<br />
ាគ ុ ងប័ណធានារ៉ប<br />
េដយេគារពេទតមលក ែដលមបែថប<br />
ក៏ដូចជាច្បជធរមានៃន្រពះរជាណាច ុង<br />
ខ ុំ/េយងសូមផល់សិទពឥដល់្រកមេហ៊ុ ឬ េមាីរបះ៍ាកមេហុបាគ ុបយរណយ្<br />
ិាាគ ុបារី ណប្េម៍េបះរូបសពែដល្រកមេហ៊ុនយល់ថាចំប<br />
I/We request you to deal on my/our behalf with the third party claims<br />
arising herein in accordance with the terms and conditions of the<br />
above-mentioned policy as well as the laws in force of Cambodia, and<br />
I/we authorize you and your attorney at law on my/our behalf to settle<br />
this case by any means that you find necessary.<br />
ៃថ ែខ ឆគ / ំ DATE:………………………………………………………………<br />
េ ឈ្ / NAME:………………………………………………………………....<br />
ហតេលខ និង ្រ / SIGNATURE AND STAMP:……………………<br />
……………………………………………………………..............................<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………<br />
………………………………………………………………………………………
Change language