*Fields compulsory to process insurance renewal.

* Full Name:

* Occupation / Designation:

* Date of Birth:

* NRIC:

* Gender Male Female

* Driving Experience: years

* No Claim Discount Yes No
If yes, specify amount.

* Veh No.:

Parallel Import Yes No

* Insurance Type
Comprehensive
Third Party Fire and Theft
Third Party Only

Martial Status
Single
Married
Others
If others, please specify.

Claims in the last 3 years
Yes
No

Insurance Expiry Date:

Current Insurer:

Referral Name:

* Email:

* Contact No.:

Additional Information

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