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Request for Quotation

Please note that the fields marked with * are mandatory.

Applicant's Particulars

*Name of Insured

:

*Marital Status

:

*Date of Birth

:

*Gender

:

Male

Female

*NRIC No

:

Nature of Business

:

*Occupation

:

*Nationality

:

*Indoor/Outdoor

:

Indoor

Outdoor

*Contact Number

:

*Email Address

:

Other Information

COE Expiry Date

:

*Years of Driving Experience

:

*Existing NCD (%)

:

*NCD Upon Renewal (%)

:

*Safe Driver Discount

:

Yes

No

*Type of Cover

:

*No. of Claims Past 3 yrs

:

Opt for Authorized workshop under Insure

:

Yes

No

Claim amount if any

:

*Period of Insurance

:

to

Name of Current Insurer (If any)

:

Vehicle Information

Registration No. (if any)

:

*Vehicle Make

:

*Vehicle Model

:

*Year of Manufacture

:

*Seating Capacity including driver

:

*Year of Registration

:

*Engine capacity

:

*Off Peak Car?

:

Yes

No

Named Driver(s) to be included if any

Name

:

Relationship

:

D.O.B.

:

Occupation

:

Gender

:

Male

Female

Years of Driving Experience

:

Marital Status

:

Claims

:

Name

:

Relationship

:

D.O.B.

:

Occupation

:

Gender

:

Male

Female

Years of Driving Experience

:

Marital Status

:

Claims

:

Name

:

Relationship

:

D.O.B.

:

Occupation

:

Gender

:

Male

Female

Years of Driving Experience

:

Marital Status

:

Claims

: