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ONLINE QUOTATION FORM - MOTOR INSURANCE
Applicant Information
*
Indicates required field
Insured Name :
*
Insured ID : (Last 4 characters e.g. 123A)
*
Gender :
*
Male
Female
Nationality :
*
Marital Status :
*
Single
Married
Others
Date of Birth : (DD MMM YYYY)
*
Driving Licence Pass Date : (DD MMM YYYY)
*
Block
*
Street
*
Unit
*
Postal
*
Mobile Number :
*
Email :
*
Employment Details
Occupation :
*
Work Environment :
*
Indoor
Outdoor
Indoor & Outdoor
Vehicle Details
Vehicle Number :
*
Parallel Import :
*
No
Yes
Off-Peak Car :
*
No
Yes
Insurance Details
Existing Insurer :
*
Renewal Date : (DD MMM YYYY)
*
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 MMM 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
Details of Additional Driver
(if applicable)
Name :
*
ID : (Last 4 characters e.g. 123A)
*
Gender :
*
Male
Female
Marital Status :
*
Single
Married
Others
Date of Birth : (DD MMM YYYY)
*
Relationship to Insured :
*
Occupation :
*
Work Environment :
*
Indoor
Outdoor
Indoor & Outdoor
Driving License Pass Date : (DD MMM 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 (if any) :
*
Granting Safe Harbour Permission to Contact Me
*
I consent Safe Harbour to contact me
Submit
Motor
Motor Insurance Quotation Form
Commercial Vehicle Quotation Form
Personal
Home Insurance
>
Home Insurance Quotation
Personal Accident Insurance
>
Personal Accident Insurance Quotation
Domestic Maid Insurance
>
Domestic Maid Insurance Quotation
CONNECT
SATISFACTION