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Commencement Date   (Format:dd/mm/yyyy Tentative date if buying a new car)
Name  
NRIC   (Used to verify safe driver discount)
Email   (Quotation will be sent to this email)
Address  
Telephone  
Birthday (dd/mm/yyyy)   (e.g 23/05/1976)
Gender   Male Female
Marital Status  
Driving Licence Pass Date   (Format:dd/mm/yyyy This info is at the back of your driving licence)
Occupation   (e.g. admin, indoor)
Safe Driver Discount   Yes No (Check Eligiblity)
No Claim Discount  
Type Of Cover Required  
Registration Number   (Please put just "S" if you are buying a new car)
Make & Model  
Engine Capacity (CC)   (e.g. 1498)
Year of Registration   (If year of made is a different year please indicate at remarks below)
Parellel Imported   Yes No
Vehicle Type  
Vehicle Usage   (If your car is off-peak car, please indicate here)
Current Insurer  
Renewal Premium   (Why you should tell us)
With NCD Protector   Yes No (Only applicable to 50% NCD holder)
Claim for the past 3 years   Yes No (If yes, please indicate details at remarks)
Remarks and
Special Requirements
  (If there is claim for the past three years, please indicate the date, claim amount and whether it is own damage claim or third party claim)
How do you know us  
Important factors to you   Price Only Agent Service Insurer Brand Policy Benefits (You may select more than one)
Please enter the characters     
 

 

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