Commercial Auto Insurance

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POLICY

Proposal Date *

Policy Inception Date *

Policy Expiry Date *

PROPOSER

For vehicle registered owner only

Proposer Name *

NRIC / Passport / FIN *

Business Type *

Business Nature *

PERSONAL INFORMATION

Please fill in this section if not a business entity

Date of Birth *

Nationality *

Marital Status *

Gender *

Job Nature *

Physical Impairment (If Any)

Driving Experience (Yrs) *

Driving Experience (Mths) *

CONTACT

Home Phone No.

Home Fax No.

Work Phone No.

Work Fax No.

Mobile No. *

Email Address *

VEHICLE

Registration Year *

Registration No.*

Vehicle Make *

Vehicle Model *

NCD Declared *

No. of Seats *

Vehicle Usage

Carry Own Goods

Carry Own Passengers

Carry Non-Employees on cargo deck

For hire to carry goods or passengers

Third Party Goods

Any Flammable Goods ? *

DECLARATIONS

Revoke / Endorsement of License

Has license been revoked before ? If yes, please specify which year

Reason

Claims Experience

Any other claims experience ? If yes, please specify which year

Reason