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INSURED'S PARTICULAR

Name
NRIC / Passport No / Fin no
Date of birth
Marital Status
Gender
Address
Postal Code
Driving Experience (years)

CONTACT INFORMATION

Handphone
Home
Office
Email

POLICY DETAILS

Policy Type

Type of coverage

Year of manufacture

Any Traffic Conviction (excl Parking Fines) in the last 3 years

Been Entitled to any No Claim Discount(NCD)?
Policy No (if existing)

Payment option

Year of registration

Any accidents on the last 3 years?

If Yes to above, please indicate amount
Vehicle no

Make & Model

Engine Capacity

If Yes to above, please give details and claims amount

Previous insurer

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Should you have any questions or concerns regarding your inquiry, please contact Ryan at 9152 1606.