Insurance Quotation Form is for

Car Owner Details

Name (required)
As per NRIC / Passport / ROC

Email (required)

Contact Number (required)

NRIC / Passport / ROC No. (required)

Place of Issue of Passport

FIN (For Passport Holder)

How Did You Hear About Us?

If others, please specify

Gender
MaleFemale

Marital Status (required)

Date of Birth (dd/mm/yyyy) (required)

Driving Licence Pass Date (dd/mm/yyyy) (required)

Type of Licence

Nationality

If Foreigner, please state

Occupation (required)

Job Environment
IndoorOutdoor

Named Driver’s Details (if any)

Name

Contact Number

NRIC / Passport / ROC No.

Place of Issue of Passport

FIN (For Passport Holder)

Gender
MaleFemale

Marital Status

Date of Birth (dd/mm/yyyy)

Driving Licence Pass Date (dd/mm/yyyy)

Type of Licence

Nationality

If Foreigner, please state

Occupation

Job Environment
IndoorOutdoor

Vehicle Details

Vehicle No. (required)

Make and Model (required)

Model Type (required)
PI ModelAgent ModelBrand New

No. of Doors (required)

Vehicle Type (required)

Existing Insurance Details (if any)

Existing Insurance Company

What is the Premium Offer Price by your existing insurance company?

Policy No.

Insurance Expiry Date (dd/mm/yyyy)

Current NCD on Policy

For New Purchase, please state NCD (%) will be transferred from which Vehicle No.:

Discount Type

Discount Value

Insurance Commencement Date (dd/mm/yyyy)

Any Accident for the past 3 years?

If Accident is at Fault, please state details

Type of Workshop

Type of Coverage

If you have (A) more than one named driver or (B) more than one accident, please put under the message/note box below. Thank you.

Message/Note

Please type the verification code below

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