About Yourself

Company Name*

Company R.O.C*

Nature Of Business Name*

Your Email (required)

Any claims for the past three years?

YesNo

Please indicate claims amount and date

NCB*

Car Details

Please note that if there is not a brand new vehicle, there is no need to fill in information on make, model. registration date, engine capacity. However, do indicate the full vehicle number.

Type of Plan*

ComprehensiveThird Party Fire and TheftThird Party

Vehicle No.*

Make

Model

Registration Date of Vehicle

Engine Capacity

Named Driver

Name

IC / FIN / Passport No.

Date of Birth

Driving Experience

Gender

MaleFemale