Tel: 6444-4644 (6 lines)

2 KALLANG AVE #08-16 CT HUB Fax: 6444-0040

SINGAPORE 339407
From
Co Name: Sales Person:
Attention

Tel: Fax:

REQUEST FOR MOTOR INSURANCE QUOTATION

INSURED'S PARTICULARS

NAME : ________________________________________ NRIC: ______________________ DATE OF BIRTH : ________________

MARITAL STATUS : MARRIED / SINGLE / DIVORCED D/EXP: _______YRS ______ MTH GENDER : MALE / FEMALE

OCCUPATION :________________________________ ( Inddor / Outdoor ) NATIONALITY : S'POREAN / PR / OTHERS

COVERAGE: COMPREHENSIVE / TPFT / TPO OFF-PEAK CAR : YES / NO

VEHICLE NO. : __________________________ MAKE & MODEL : ________________________________________________

YR MAKE : _____________REG YR____________________ ENGINE CAPACITY : ____________ PARALLEL IMPORT : YES / NO

SEATING CAP : ________ BODY TYPE : Saloon / Coupe / High Performer / MPV / SUV MODIFICATIONS : YES / NO

DETAILS OF PREVIOUS INSURANCE

NCD : __________ % EXISTING VEHICLE NO. : ________________________ EXISTING INS. CO. : ____________________

CLAIMS DETAILS (PAST 3YRS) :________________________________________________________________________________

NAMED DRIVER'S PARTICULARS

NAME : _________________________________ NRIC: _________________________ DATE OF BIRTH : __________________

MARITAL STATUS : MARRIED / SINGLE / DIVORCED D/EXP: ________YRS _______ MTH GENDER : MALE / FEMALE

RELATION TO PH : ___________________ OCCUPATION :________________________ NATIONALITY : S'POREAN / PR / OTHERS

Insurer Premium Excess Authorised Workshop

______________ _____________________________ _______________ Yes / No

______________ _____________________________ _______________ Yes / No

______________ _____________________________ _______________ Yes / No

Remarks ___________________________________________________________________________

___________________________________________________________________________