REGISTRATION FORM

Personal Particulars

Full Name*

Gender*

ID Type*

NRIC / Passport No*

Date of Birth*

Nationality*

Hidden

Nationality

Occupation*

Work Environment*

What is your marital status?*

Single

Married

Divorced

Widowed

Mobile Number*

Important notice

Statement to section 25(5) of the Insurance Act (Cap. 142). You are to disclose fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder may be void.

REGISTRATION FORM

Address

Postal Code

ZIP / Postal Code

Building Name

House No./ Blk*

Floor Level

Unit No

Street Name*

Country*

Important notice

Statement to section 25(5) of the Insurance Act (Cap. 142). You are to disclose fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder may be void.

REGISTRATION FORM

Driver Details

Driving Licensed Date*

NCD Entitlement Upon Renewal*

Claim Experience (Past 3 years)*

Are you the main driver?*

Is there an additional driver?*

Is there an additional driver 2?*

Important notice

Statement to section 25(5) of the Insurance Act (Cap. 142). You are to disclose fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder may be void.

REGISTRATION FORM

Insured Vehicle Details

Vehicle Usage*

Promotion Code

Important notice

Statement pursuant to section 25(5) of the Insurance Act (Cap. 142) -You are to disclose fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder may be void.

Personal Particulars

Address

Driver Details

Insured Vehicle Details

I have a account

I do not have a account