Motor Insurance

Contact Number *

Email *

Name of Insured *

NRIC / FIN *

Date of Birth *

Gender *

Nationality *

Marital Status *

Occupation *

Nature of Business

Driving Experience *

Claims Information

Claims Experience for Past 3 Years *

Date of Accident

Nature of Claim

Claim Amount

Own Damage

Third Party Damage

Other

Vehicle Registration Number *

Type of Coverage *

Any Workshop or Authorised Workshop *

No Claim Discount (On Renewal) *

How many years have you enjoyed 50% No Claim Discount?

Reason

NCD Protector

Additional Named Driver

Name *

NRIC / FIN *

Gender *

Date of Birth *

Occupation *

Driving Experience *

Existing Insurer

Renewal Premium Inclusive GST

Vehicle Make / Model

Year Of Manufacture

Registration Date

Vehicle Body Type

Parallel Import

Vehicle Usage

Cubic Capacity (cc)

Period Of Insurance

From *

To *

Good Driver Discount (5%) *

Yes

No

Remark

Terms and Conditions *

I have read and agree to the Terms and Conditions

Please read our Terms & Conditions before submitting this form.

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Personal

Commercial

Claims Information

Additional Named Driver

Period Of Insurance