Car Insurance Enquiry
Owner’s Particulars
Name:
Male
Female
Address:
Email:
Home Tel:
Mobile Phone:
Off Tel:
NRIC:
D.O.B( dd/mm/yy):
Name of Employer:
Age
:
Occupation:
Job Nature
Indoor
Oudoor
Date obtained Licence (dd/mm/yy)
Driving Exp (Yrs):
Claims Experience
Do you have any claim in the last 3 years ?
Yes ( Pls fill in the claim amount )
No
a)Total Claim Amt : $
b)Claim By Third Party: $
c)Own Damage Claim : $
.
Any Traffic Conviction in the last 3 years ?
Yes ( Pls give details)
No
Current Insurance Company
Name of Insurance Co
No Claim Discount
Select
10%
20%
30%
40%
50%
Type of Cover
Select
Comprehensive
3rd Party Fire Theft
Third Party Only
PARTICULARS OF VEHICLE
Reg No
Engine Capacity
Vehicle Make
Original Reg Date :
Year of Make
Type of Vehicle
Select
Private Car
Commerical Vehicle
Private Bus
Tonnage
(for commercial vehicle only)
