Private Settlement Form

Accident Details

Location Date & Time

Motor Vehicle 1

Registration Number Owner's Name & NRIC No. Driver's Name & NRIC No.

Motor Vehicle 2

Registration Number Owner's Name & NRIC No. Driver's Name & NRIC No.

Settlement Details

1. The parties involved have agreed to settle this incident amicably as follows (delete where necessary) :
- Responsibilites for any losses or damage (directly or indirectly) that has arisen from the incident shall be absolved.
- Without any admission of liability, the Party Paying Compensation will pay a sum of $ _________ of the vehicle repair costs
incurred/to be incurred by the Party Receiving Compensation.

2. The parties involved have agreed to that there are no personal injuries, and no police report, insurance claims,
or legal actions can be taken in regards to this accident.

Particulars

Do note that information collected through this private settlement arrangement may be kept by your respective insurers for internal
investigation, administering claims, as well as for fraud detection and future insurance applications

Name & NRIC / Passport Number (Party Paying Compensation) Name & NRIC / Passport Number (Party Receiving Compensation)

Contact Number: Contact Number

Signature Signature

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losses, damages or expenses arising from the usage of this document.