Note: All 'motor-related' fields are required before submission can be processed.

Name of Insured (required)

NRIC (required)


Class 3 Driving License Pass Date

Sex                   Marital Status

Date of Birth

Contact No.

Your Email (required)

Vehicle No.

Current Insurance Co.

No Claim Discount

Current Insurance Co.

Any claims within past 3 years
    If 'yes', please state amount

Parallel Import?