Motor Quotation

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Motor Quotation

Statement pursuant to Section 25(5) of the Insurance Act (Cap 142) or any subsequent amendments thereof, you are to disclose in this enrolment form, fully and faithfully, all the facts which you know or ought to know in respect of the risk that is being proposed, otherwise, the policy issued hereunder may be void.

My Choice of Plan (Please Indicate)

Period of insurance * From

Period of insurance * To

Coverage *

Third Party Only
Third Party Fire And Theft
Comprehensive

My Personal Particulars

Surname *

Given Name

Email *

NRIC/Passport No *

Date of Birth *

Sex *

Male
Female

Marital Status *

Single
Married
Divorced

Nationality

Race

Tel Home

Handphone *

Fax No

Address

Postal Code

Occupation *

Years of Driving Experience *

NCD *

Safe Driver's Discount

Yes
No

Details of Vehicle

Make *

Model *

Vehicle Registration No *

Seating Capacity

Year of Manufacture *

Year of Registration

Engine Capacity

Weekend Car

Yes
No

Any Modifications?

Yes
No

Additional Drivers If Any ?

Yes
No

Claim History

Date of Accident

Name of Insurance Company

Details of Claim

Amount of Claim

Have you or your named driver(s) been given demerit points for traffic offences?

Yes
No

Have you or your named driver(s) suffered any disease or infirmity that could impair the ability to drive?

Yes
No

Are you our existing motor policyholder? *

Yes
No