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Type of Coverage Comprehensive 3rd party Fire & Theft Third Party Only
Details of Registered Owner
Name of Owner
Nric No/Date of Birth(DMY) /   Gender M F
Marital Status Single Married Others
Occupation/Employer / / Indoor Outdoor
Telephone/Mobile /
Email Address
Are you driving the car? No Yes years of driving experience
Details of the Vehicle/Car
Vehicle Registration No Saloon MPV/Stationwagon SUV
Make/Model of car /
Date of Regn / Engine Capacity cc / Parallel Import No Yes
Other Details
No Claim Discount(NCD) Nil 10% 20% 30% 40% 50%
OFD / Current Insurer No Yes
Finance COmpany
Claims for past 3 years (Amount claim & Date of Accident) Accident Date Own Damage 3rd Party
Details of Other Drivers
Name of Driver/Relation
Occupation / Driving Experience / Indoor Outdoor years
Nric No/Date of Birth(DMY) /   Gender M F

Remarks


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