3% MUA Claim Number: 1199/22/MK/KIG Novernber 28, 21 To Claimant +_- MOTA-ENGIL,ENGENHARIA E CONSTRUCAO. Address : MASORO Telephone + 0784838784 Dear Sir/ Madam, RE: Claim Notice Acknowledgement WITHOUT PREJUDICE AND ADMISSION OF LIABILITY We hereby acknowledge receipt of your claim intimation forthe accident which Occured on + November 26, 2022 ‘And was intimated to uson : November 28, 2022 Under Policy Number 671/19 Insurance Class PRIVATE CAR Department : MOTOR Your claim has been recorded in our books under reference number above which should be quoted in any correspondance or follow-up related to this issue, ‘You are therefore requested to submit tous, the following ticked supporting documents es indicated below: [C1 &- Dectaration Form > Driving License 3- Repair Estimates 4- Police report/statement [EX 5- Proof of Payment of Excess lity shall be determined upon reception of supporting documents as above. Therefore, this notice does not constitute an admission of liability at this stage and does not prejudice any of claimant's rights. Always assuring you our better services. Yours faithfully, anda Nin Aves, Grand Penson Pies, Goan & fi os, ign, Rod T 4250252570331 mua.rw3% MUA Adgdlorlivivig MOTOR INSURANCE CLAIM FORM ‘Fm onare a te is of is oem fe not constteminislon ay. Pe inommes atthe Gecradon of curr, ea sence of 4. POUSY NOLDERCLAMNT DETARS sone [6[6]7] 41/14) 9] ll vation 13/1} /foisiriafojai2; 11] EEE | Mota-Engi Engenharia e construgto 2f {TT T ielsiviefele | Seceetiage KG. 415.80, ate No. 6 Gacuciro {temas | felZ fe To ay vem Co [ete Woah nieorven aa 3 Presna “| ewotimee | TTT PTT | Petrstnag. ef el Prsseetore [Mots Engl Atioa, Rwanda | Pessteesower_|UMUTONIWASE JENNIPHER pases tower KG, 415 Av. Gala Nos, Gaaugra | js atone [Riemom rome | ae [pease | itisielvjefofaisii] 7 | festeweom: [olrialelaii ofoyaioy vate IMUA INSURANCE LTD “&_ DAMAGES TO VENICLES OR OTHER PROPERTICS 4 a Penage oiandvanas yl SEE ATTACHED PIGTURES af al 5 i ef aaa] E a re aa | | Fee? WOTA-ENGIL | eNGeNHARIA E CONSTRUGAO | |f_COCUPANT/ PASSENGER! THIRD PARTY IUURY DETALS [Fo ation ansuor by Fanly (a Empey or Tid Forty 7 [Piste accicen caused utes Or yes dete of injored persons] [ves Vv] ke [proce Aas whee Se penee wel Tomiorainieced] Onsager ce wees Bette oe crneme | ar oe | ZN [ARM INJURED a] i 28 Nv 7 S._ DRIVER INFORMA ECEPTION | EDMILSON | ToT Tomar cone [|i Te folefefolapayilaiaye [eee il STATE E Tveseuns (1]417 ajafifs|2 Ua wninpsie Sinton | BUGESERA i [itvoud repo scien poie, ati the as? Setemmmeme al le EEE soeemesess te soeimets Semngiemceeriay "tyes [Vy |_| Manes vewwen [VW Sa = |i was following behind a car on the ‘ight side. When she suddenly tried to oross the. ‘oad just after the in front had overtaken the place where re she was. | swerved to the left side of the road braking, but as _ ishe keeps crossing the road, | ended up hitting. Treoterpary ven) | SKETGIOF THE ACSOENT Sis Be Sab yer So See Re Seager oes B yor tert mm i "RUBO D0 YOU HANES FAULTY WTHERCSOST ie TreohePey [Tome ee _[ Waa I "Wry co yeu ass) TSE | T Dene Tages es ‘Signars of newreelOnae Stamp ircersorsts) Sono \ NoeNitanesconsTRUGAC \ \ FRIGA, SA oe {sie Sane 87a, T2T2