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

Gender
 Male Female