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About the Insured :
Name * ( Individual / Company )
Last 4 Characters of NRIC/FIN *
Date of Birth *
Sex *

Marital Status *
Occupation *
Years of Driving Experience *
Contact No. *
Email Address
About the Vehicle :
Vehicle No. *
Current Insurer *
NCD upon Renewal *
Any Claim in last 3 years? *


If Yes, Total Claim Amount
Type of Cover *

Source/Promotion Code :
*Compulsory fields needed for quote


Important Notice: Statement Pursuant to Section 25(5) of the Insurance Act (Cap. 142) - You are to disclose in this form fully and faithfully all the facts which you know or ought to know, otherwise the policy issued may be void.

The insurance will not be in force until the application and premium have been received and accepted by the company.

Please note that by submitting this form, you are deemed to have given us the consent to collect, use and disclose the information for the purpose of obtaining the quotation; and also to contact you via (phone/fax/text/email) on matters related to motor insurance.




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