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FIN/NRIC
:
Date of Birth
:
Given Name
:
Surname
:
Gender
:
Male
Female
Nationality
:
-- Please select --
Singapore
United Kingdom
United States
Australia
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling); Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d`Ivoire
Croatia (Hrvatska);
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands/Malvinas
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Is.
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Lao People`s Dem. Rep.
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Is.
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S.Georgia & S.Sandwich Is.
Saint Kitts and Nevis
Saint Lucia
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Slovakia (Slovak Republic);
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Minor Outlying Is.
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican (Holy See);
Venezuela
Viet Nam
Virgin Islands (British);
Virgin Islands (U.S.);
Wallis & Futuna Is.
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Address
:
Address 2
:
Postcode
:
Country
:
-- Please select --
Singapore
United Kingdom
United States
Australia
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling); Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d`Ivoire
Croatia (Hrvatska);
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands/Malvinas
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Is.
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Lao People`s Dem. Rep.
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Is.
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S.Georgia & S.Sandwich Is.
Saint Kitts and Nevis
Saint Lucia
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Slovakia (Slovak Republic);
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Minor Outlying Is.
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican (Holy See);
Venezuela
Viet Nam
Virgin Islands (British);
Virgin Islands (U.S.);
Wallis & Futuna Is.
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Telephone
:
Mobile
:
Email
:
Confirm Email
:
Occupation
:
Employer
:
Job Nature
:
Mostly Indoor
Mostly Outdoor
Year driving license obtained?
:
Marital Status
:
Married
Single
Type of Plan
:
Comprehensive
Third Party Fire and Theft
Third Party Only
Additional drivers
:
No
Yes
1
2
3
Driver 1
Driver 2
Driver 3
Given Name
:
Surname
:
FIN/NRIC
:
Date of Birth
:
Nationality
:
-- Please select --
Singapore
United Kingdom
United States
Australia
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling); Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d`Ivoire
Croatia (Hrvatska);
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands/Malvinas
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Is.
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Lao People`s Dem. Rep.
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Is.
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S.Georgia & S.Sandwich Is.
Saint Kitts and Nevis
Saint Lucia
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Slovakia (Slovak Republic);
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Minor Outlying Is.
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican (Holy See);
Venezuela
Viet Nam
Virgin Islands (British);
Virgin Islands (U.S.);
Wallis & Futuna Is.
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
-- Please select --
Singapore
United Kingdom
United States
Australia
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling); Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d`Ivoire
Croatia (Hrvatska);
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands/Malvinas
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Is.
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Lao People`s Dem. Rep.
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Is.
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S.Georgia & S.Sandwich Is.
Saint Kitts and Nevis
Saint Lucia
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Slovakia (Slovak Republic);
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Minor Outlying Is.
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican (Holy See);
Venezuela
Viet Nam
Virgin Islands (British);
Virgin Islands (U.S.);
Wallis & Futuna Is.
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
-- Please select --
Singapore
United Kingdom
United States
Australia
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling); Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d`Ivoire
Croatia (Hrvatska);
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands/Malvinas
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Is.
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Lao People`s Dem. Rep.
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Is.
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S.Georgia & S.Sandwich Is.
Saint Kitts and Nevis
Saint Lucia
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Slovakia (Slovak Republic);
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Minor Outlying Is.
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican (Holy See);
Venezuela
Viet Nam
Virgin Islands (British);
Virgin Islands (U.S.);
Wallis & Futuna Is.
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Gender
:
Male
Female
Male
Female
Male
Female
Occupation
:
Year driving license obtained
:
Marital Status
:
Married
Single
Married
Single
Married
Single
Relationship to Policy Holder
:
Policy start date
:
Please tell us about your vehicle
Make
:
Model
:
Engine Capacity (cc)
:
Registration No.
:
Hire Purchase
:
Yes
No
Vehicle Use
:
Own Use
For Hire
Hire Purchase Company
:
Modifications
:
Yes
No
Off peak car?
:
Yes
No
Please tell us about your claims bonus
No Claim Bonuses (NCB) :
None
1year 10%
2year 20%
3year 30%
4year 40%
5year 50%
Indicate the reason your NCB is less than 10%
:
First time owner
:
2nd or 3rd vehicle
:
Have been driving company vehicle
:
Other
Is NCB to be transferred from existing/ previous insurer ?
:
Yes
No
Previous Insurer
:
Registration No.
:
Policy No.
:
Expiry/Cancellation Date
:
Have any drivers proposed under this policy had a Claim in the last 3 yrs ?
:
Yes
No
Date of Accident
:
Description of Accident
:
Amount of Claim
:
Type of Claim
:
Own Damage
Third Party
Theft
Bodily Injury
Submit