INSURANCE

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Insured’s Particulars

Your Name*
NRIC/Passport no/Fin no.*
Date of Birth (ddmmyy)
Marital Status
Gender
Address

Contact Information

Handphone*
Home
Office
Email

Policy Details

Policy Type
Policy No. (if existing)
Vehicle No.
Type of Coverage
Payment Option
Make and Model
Year of Manufacture
Year of Registration
Engine Capacity
Any Traffic Conviction in the last 3 years? (excluding Parking Fines)
Any Accident in the last 3 years?
If Yes to above, please give details and claims amount:
Been Entitled to any No Claim Discount(NCD)?
If Yes to above, please indicate amount
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