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About Yourself
Insured* (Full name)
IC
Your Email (required)
Is the insured driving?* Yes No
Date of Birth*
Driving Experience*
Gender Male Female
Any claims for the past three years? Yes No
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 Yes No
Name
IC / FIN / Passport No.
Date of Birth
Driving Experience