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ONLINE QUOTATION FORM - MOTOR INSURANCE
Personal Particulars
Name :
*
Gender :
*
Male
Female
NRIC :
*
Nationality :
*
Marital Status :
*
Single
Married
Others
Date of Birth : (DD/MM/YYYY)
*
Driving Licence Pass Date : (DD/MM/YYYY)
*
Block
*
Street
*
Unit
*
Postal
*
Contacts Details
Home Number :
*
Office Number :
*
Mobile Number :
*
Email :
*
Employment Details
Occupation :
*
Nature Of Business :
*
Work Environment :
*
Indoor
Outdoor
Indoor & Outdoor
Vehicle Details
Vehicle Registration Number :
*
Parallel Import :
*
No
Yes
Off-Peak Car :
*
No
Yes
Insurance Details
Existing Insurer :
*
Renewal Date : (DD/MM/YYYY)
*
Renewal Premium ($) :
*
NCD Upon Renewal :
*
0%
10%
15%
20%
30%
40%
50%
Good Driver Discount
*
No
Yes
Finance Company :
*
Claim Experience for last 3 years :
*
No
Yes
If yes, Date of Claim: (DD/MM/YYYY)
*
Own Damage Claim Amount, if any (S$) :
*
Third Party Damage Claim Amount, if any (S$):
*
Type of Coverage Required :
*
Comprehensive
Third Party Fire & Theft
Third Party Only
Additional Benefits Required :
*
NCD Protector (50% NCD Only)
Courtesy Car
Any Workshop
Warranty Workshop
Waiver of Excess
Particulars of Other Named Drivers (if any)
Name :
*
NRIC :
*
Gender :
*
Male
Female
Marital Status :
*
Single
Married
Others
Date of Birth : (DD/MM/YYYY)
*
Relationship to Insured :
*
Occupation :
*
Work Environment :
*
Indoor
Outdoor
Indoor & Outdoor
Driving License Pass Date : (DD/MM/YYYY)
*
Claim Experience for last 3 years :
*
No
Yes
If yes, Date of Claim : (DD/MM/YYYY)
*
Own Damage Claim Amount, if any (S$) :
*
Third Party Damage Claim Amount, if any (S$) :
*
Remarks :
*
Promo Code (if any)
*
Consent for Safe Harbour Assurance Agency to call me for any further clarification and/ or providing quotation pertaining to the service that I enquire.
Please tick below to give consent.
*
I consent
Submit
Motor
Motor Insurance Quotation Form
Commercial Vehicle Quotation Form
Personal
Travel Insurance
>
Travel Insurance Quotation Form
Home Insurance
>
Home Insurance Quotation Form
Personal Accident Insurance
>
Personal Accident Insurance Quotation Form
Domestic Maid Insurance
>
Domestic Maid Insurance Quotation Form
CONNECT
SATISFACTION
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