Car Insurance Free Quotation

Insurance Quotation Form is for

Car Owner Details

Name (required)
As per NRIC / Passport / ROC

Email (required)

Contact Number (required)

NRIC / Passport / ROC No. (required)

Place of Issue of Passport

FIN (For Passport Holder)

How Did You Hear About Us?

If others, please specify

Gender
 Male Female

Marital Status (required)

Date of Birth (dd/mm/yyyy) (required)
[date* dob date-format:dd/mm/yy]

Driving Licence Pass Date (dd/mm/yyyy) (required)
[date* licence-pass-date date-format:dd/mm/yy]

Type of Licence

Nationality

If Foreigner, please state

Occupation (required)

Job Environment
 Indoor Outdoor

Named Driver's Details (if any)

Name

Contact Number

NRIC / Passport / ROC No.

Place of Issue of Passport

FIN (For Passport Holder)

Gender
 Male Female

Marital Status

Date of Birth (dd/mm/yyyy)
[date dob-b date-format:dd/mm/yy]

Driving Licence Pass Date (dd/mm/yyyy)
[date licence-pass-date-b date-format:dd/mm/yy]

Type of Licence

Nationality

If Foreigner, please state

Occupation

Job Environment
 Indoor Outdoor

Vehicle Details

Vehicle No. (required)

Make and Model (required)

Model Type (required)
 PI Model Agent Model Brand New

No. of Doors (required)

Vehicle Type (required)

Existing Insurance Details (if any)

Existing Insurance Company

What is the Premium Offer Price by your existing insurance company?

Policy No.

Insurance Expiry Date (dd/mm/yyyy)
[date insurance-expiry-date date-format:dd/mm/yy]

Current NCD on Policy

For New Purchase, please state NCD (%) will be transferred from which Vehicle No.:

Discount Type

Discount Value

Insurance Commencement Date (dd/mm/yyyy)
[date insurance-commencement-date date-format:dd/mm/yy]

Any Accident for the past 3 years?

If Accident is at Fault, please state details

Type of Workshop

Type of Coverage

If you have (A) more than one named driver or (B) more than one accident, please put under the message/note box below. Thank you.

Message/Note

Please type the verification code below

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