APPLICATION FOR MOTOR INSURANCE All information entered is strictly kept confidential.

Full name of Proposer :
Gender :	----- Male Female
Date of Birth :	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ------ Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ------ Year 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 ------
New IC No (Old IC) :
Residence Address :
Correspondence address :
Occupation :
Contact tel. number :
Email address :
Period of insurance required :
Type of vehicle :	Private use       Commercial use
Make/Type/Model :
Year of manufacture :
Cubic capacity :
NCD entitlement % :
Any accident past 3 years?	Yes       No
Sum Insured (RM) :
Additonal perils required :	Passengers liability   Windscreen damage   Flood   Riot, Strike & Malicious damage   P/accident to unnamed passengers  All drivers for commercial vehicle only  Other perils required, please type at box below.
Other specific perils required :
Expiry date of Road Tax :
Please check to see that your form is duly completed before you submit.  Thanks.
If you have any query, please use our Enquiry form or call  012-5158027 or e-mail us