Request Quotation

Sum insured

Period of insurance (dd/mm/yyyy)

Day Month Year

Coverage *

Third Party Only Third Party, Fire and Theft Comprehensive

Surname *

Given Name *

Email

NRIC *

Date of Birth: (dd/mm/yyyy)

Day Month Year

Gender *

Male Female

Marital Status: *

Nationality:

Race

Contacts:

Fax

Address

Occupation *

Name of Company

Type of Industry

Years of Driving Experience *

NCD (%) *

Safe Driver's Discount:

Yes No

Make *

Model *

Body Type: (e.g. coupe, sedan, hatchback etc) *

Vehicle Registration No *

Seating Capacity *

Year of Manufacture *

Year of Registration *

Engine Capacity (cc) *

Weekend Car

Yes No

Any Modifications

Yes No

Additional Drivers (If any):

Yes No

Driver 1

Surname

Given Name

NRIC

Date of Birth: (dd/mm/yyyy)

Day Month Year

Gender *

Male Female

Marital Status: *

Relationship

Nationality:

Race

Occupation *

Years of Driving Experience *

Claim if Any

Driver 2

Surname

Given Name

NRIC

Date of Birth: (dd/mm/yyyy)

Day Month Year

Gender *

Male Female

Marital Status: *

Relationship

Nationality:

Race

Occupation *

Years of Driving Experience *

Claim if Any

Date of Accident (dd/mm/yyyy)

Day Month Year

Name of Insurance Company

Details of Claim

Amount of Claim

Date of Accident (dd/mm/yyyy)

Day Month Year

Name of Insurance Company

Details of Claim

Amount of Claim

Date of Accident (dd/mm/yyyy)

Day Month Year

Name of Insurance Company

Details of Claim

Amount of Claim

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

No Yes (Please specify the driver and the No. of demerit points accumulated in the past 24 months)

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

No Yes (Please specify)

Are you our existing motor policyholder?

No Yes

Please note that the liability of the company does not commence until this proposal has been accepted by the company.

Request Quotation

My Choice of Plan (Please Indicate)

My Personal Particulars

Details of Vehicle

Claims History (Last 3 Years)