Motor Insurance

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POLICY

Proposal Date *

Policy Inception Date *

Policy Expiry Date *

PROPOSER

Proposer Name *

NRIC / Passport / FIN *

Date of Birth *

Nationality *

Marital Status *

Gender *

Occupation *

Job Nature *

Will proposer be driving? *

DRIVING EXPERIENCE

Years *

Months *

NAMED DRIVERS (IF ANY)

NAMED DRIVERS 1

Name

Date of Birth

Driving Exp (Yrs)

Driving Exp (Mths)

Job Nature *

NAMED DRIVERS 2

Name

Date of Birth

Driving Exp (Yrs)

Driving Exp (Mths)

Job Nature *

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 *

Vehicle Usage *

CC *

Body Type *

No. of Seats *

NCD Declared *

Insured with COE / PARF ? *

Off Peak Car *

Driver Age Condition ? *

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Has license been revoked before ?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