AutoPlus Commercial PF P1.

ai

3/7/08

10:09:12 AM

COMMERCIAL AUTOPLUS MOTOR INSURANCE PROPOSAL FORM

OTHER IMPORTANT NOTES:

If the vehicle you are purchasing is registered under company's name, please endorse the company's stamp on the Proposal Form. An Elderly, Young and/or Inexperienced Driver Excess (EYIDR) of S$2,000 in addition to the Policy Excess applies to You or an Authorised Driver (Named and Un-named) who is above age 65, below age 23 (if applicable) and/or has less than 1 year's driving experience. For policy owned by an Individual, an Un-named Driver compulsory excess of S$500 in addition to any other Excess that may be applicable under this Policy will be imposed on any Driver who is not named in the Policy. Kindly attach payment with Proposal Form.

American Home Assurance Company, Singapore (AHAC) is a member company of American International Group, Inc (AIG). Incorporated in the United States with liability limited. American Home Assurance Company Singapore

AutoPlus Commercial PF P2-P4.ai

3/7/08

10:10:37 AM

COMMERCIAL AUTOPLUS PROPOSAL FORM

(For commercial vehicles only)

Important Note: An Elderly, Young and/or Inexperienced Driver Excess (EYIDR) of S$2,000 in addition to the Policy Excess applies to You or an AuthorisedDriver (Named and Un-named) who is above age 65, below age 23 (if applicable) and/or has less than 1 year's driving experience.

For policy owned by an Individual, an Un-named Driver compulsory excess of S$500 in addition to any other Excess that may be applicable under this Policy will be imposed on any Driver who is not named in the Policy.

PAYMENT MODE
Cash Cheque. Please make cheque payable to: American Home Assurance Company Bank Cheque No I/We hereby authorise American Home Assurance Company, Singapore (AHAC) to charge the stated annual premium to the following credit card. Where a third party credit card is used, I/we declare that the cardholder has authorised and consented to its use. Credit Card (MasterCard/Visa/American Express) [Please tick () accordingly] Full Annual Payment 0% Interest Installment Payment with DBS/POSB credit card 12 Monthly 0% Interest Installments with DBS/POSB credit card 6 Monthly 0% Interest Installments with DBS/POSB credit card Name as on card: Card No:
(If you are an American Express Cardholder, please fill up your card number from the second box)

Card Expiry Date:

M M Y
S$

Amount:

Subject to DBS Card Agreement Terms & Conditions

Not applicable for DBS Corporate Card and DBS/AMEX Affinity Card.

This is an authorised workshop scheme which requires all accident repairs to be done at any of the AHAC Authorised Workshops listed in the Certificate of Insurance. If this proposal is accepted or when the cover commences, it is a fundamental and absolute Special Condition of this contract of insurance that for individually-owned policies, the premium due must be paid to the insurer/broker/agent before the inception of the cover. This document is not a contract of insurance. The specific terms, conditions and exclusions applicable to the insurance are set out in the Policy. No insurance is in force until the Company has accepted this Proposal.

Reference No: PL-PF301-02/08 American Home Assurance Company Singapore

American Home Assurance Company, Singapore (AHAC) is a member company of American International Group, Inc (AIG). Incorporated in the United States with liability limited. American Home Assurance Company Singapore