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Motor
- Motor Insurance Quotation Form
- Commercial Vehicle Quotation Form
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Motor Insurance Quotation Form

Applicant Information

* Indicates required field

Insured Name : *

Insured ID : (Last 4 characters e.g. 123A) *

Gender : *

Male Female

Marital Status : *

Single Married Others

Date of Birth : (DD MM YYYY) *

Driving Licence Pass Date : (DD MM YYYY) *

Mobile Number : *

Email : *

Employment Details

Occupation : *

Work Environment : *

Indoor Outdoor Indoor & Outdoor

Insurance Details

Vehicle Registration Number : *

Existing Insurer : *

Renewal Date : (DD MM YYYY) *

NCD Upon Renewal : *

0% 10% 15% 20% 30% 40% 50%

Claim Experience for last 3 years : *

No Yes

Type of Coverage Required : *

Comprehensive Third Party Fire & Theft Third Party Only

Details of Additional Driver (if applicable)

Name *

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) *

Mailing Information

Please furnish the following information to enable us to mail the gift to you.

Block and Street Name *

Unit *

Postal *

Granting Safe Harbour Permission to Contact Me *

I consent Safe Harbour to contact me

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Motor
- Motor Insurance Quotation Form
- Commercial Vehicle Quotation Form
Personal
CONNECT
SATISFACTION

Exclusively for New Customers Only

Motor Insurance Quotation Form﻿

Services

Company

Support

Motor Insurance Quotation Form