Email 1. Coverage and Period of Insurance Choice of Coverage * -- Select Choice of Coverage -- Comprehensive Third Party Fire & Theft Third Party Period of Insurance * to * 2. Vehicle Details Vehicle Number * Parallel Import * -- Select Parallel Import -- Yes No Modified Vehicle * -- Select -- Yes No Vehicle Make and Model * Off-peak car? * -- Select -- Yes No Finance Company Sum Insured (Optional) 3. Proposer (Vehicle Registered Owner Only) Full Name (As per NRIC or ROC) * Date of Birth * NRIC / ROC Number * Gender * -- Select Your Gender -- Male Female Occupation * Marital Status * -- Select Your Marital Status -- Married Single Divorce Licence Passing Date * Email * Contact Number * Address * No Claim Discount (NCD) * 0% 10% 20% 30% 40% 50% Previous Insurer * -- Select Previous Insurer -- NIL Allianz Insurance Company of Singapore Private Limited Aviva Ltd. AIG Asia Pacific Private Limited MSIG Insurance (Singapore) Private Limited Axa Insurance Singapore Private Limited China Taiping Insurance (Singapore) Private Limited Direct Asia Insurance (Singapore) Private Limited EQ Insurance Company Limited First Capital Insurance Limited HL Assurance Private Limited (a member of Hong Leong Group) India International Insurance Private Limited Liberty Insurance Pte Ltd C/o Liberty Mutual Lonpac Insurance Berhad Etiqa Insurance Berhad, Singapore Branch Mitsui Sumitomo Insurance (Singapore) Private Limited Overseas Assurance Corporation Ltd Overseas Union Insurance Limited QBE Insurance International Limited Royal and Sun Alliance Insurance (Singapore) Limited Ergo Insurance Pte. Ltd. Shenton Insurance Private Limited Tenet Sompo Insurance Private Limited Tokio Marine Insurance Singapore United Overseas Insurance Limited Zurich Insurance (Singapore) Others 4. Claim Experience Claims in the past 3 years? * -- Select -- Yes No Suspension of Driving * -- Select -- Yes No 5. Additional Named Driver Additional Named Driver * -- Select -- Yes No Attachment (If attaching more than 1 file, zip it before attaching) Remarks I/we hereby understand that I/we need to disclose our personal data in order for Ivan Insurance Brokers Pte Ltd to generate a quotation for me/us. I/we agree that my/our declaration and disclosures herein are truthful and to the best of my knowledge. I/we agree and understand that accuracy of quotation premium is solely reliant on information provided by me/we only.