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Mutual $ettlement Forrn

When inyolved in a motor accident, you can choose to enter lnto a private setilement witrr the
OWNER of ihe other car if there are:-

- no personal injuries ot deatt of motorist and/or pedesfians

- damages are minor
- no involvement in chaln coll sions

tn," priuate settlement, both parties agree to settle the matter amieably without suing each
Yil::,

It is a Iegaily binding agreBm€ r'rt.

1. Details of the Accideni:-

Date (ddlmm/yyyy) : Tirnb:
Localion:

2a. Vehioie registratlon no. dnven by

(Name & Nric no)and ow'ed by (Name & Nric no).

2b. Vehicle registratipn no. driven by

(Name & Nric no) and owned by (Name &Nric no).

3. The pariies have agreed tt settla this matier amicably as foiJows: *delete a or b as applicable.

*a. Neither partv shail bs ' .ole to compensate lhe other party for any loss or damqges incurred or
To be incured as a res.rlt of the accldent.

*h. liabill$
Wfthout any admissi,on of tparty paytng oompensation)

compensation) hereb;' acknowledge recetpt ihereof in full and flnal setiiement o't all damages
and costd incured ang ci io be incuned as a resuli of the accidenl

4- There are no personal injL. es to the undersigned parties.

5.
Vehicle A no. : Vehicle E no, I

Name

NRIC no.

Address L7

Tel no.

Srgrnature
&.Date