Motor Insurance Proposal Form 1 Details of Registered Owner2 Particlars of Insured Vehicle3 Particulars of Named Driver4 Other Details5 Questionaire Name of Proposer*NRIC/ CO. Reg No*Date of Birth* Mailing Address* Street Address Occupation/ Business*Gender*MaleFemaleNature of Occupation*IndoorOutdoorMarital Status*SingleMarriedOthersDate Obtained Driving License* Driving Experience (Years)*Email Address* Contact No*Period of Insurance From* Period of Insurance To* Proposer's Past 3 Years Claim History Is the company register under GST? If "Yes", Please Specify:GST Registered*YesNoGST Reg Number*Proposer's Past 3 Years Claim HistoryInsured Claims Experience (Past 3 Years)*YesNoDate of Accident* Claim Amount(OD/TPPD/TPI)*Description* Usage of VehiclePrivateOff-Peak CarCompanyHireRegistration No*Type Of Body*Make*Manufacture Year*Model*Registration Year*CC/ Tonnage*Chassis No.*Engine No.*Hire Purchase*Sitting Cap (Including Driver)For Commercial Vehicle - Please Specify Attachments, If AnyHood Or CanopyPower TailgateCrane Driver 1Name of DriversNRICGenderMaleFemaleDate of Birth OccupationMarital StatusSingleMarriedOthersDriving Experience (Years)RelationshipDriver 2Name of DriversNRICGenderMaleFemaleDate of Birth OccupationMarital StatusSingleMarriedOthersDriving Experience (Years)RelationshipDriver 3Name of DriversNRICGenderMaleFemaleDate of Birth OccupationMarital StatusSingleMarriedOthersDriving Experience (Years)Relationship Other DetailsType of Cover*ConprehensiveThird Party Fire & TheftThird PartyType of Vehicle*Private CarCommercialMotor cycleType of Proposer*IndividualCorporateDetails of Previous InsurerNCD Renewal (%)*Please provide details: First Time Ownership/ 2nd or 3rd vehicle or due to Claim Experience(Delete Accordingly)Has the vehicle been modified/ converted in any way from the Maker specification*YesNoIf Yes, Please Specify*Vehicle Number*Expiry/ Cancellation date* Existing Insurance Company* Vehicle Usage - Private Vehicle1 - Social, Domestic and Pleasure and for the insured's own business or profession*YesNo2 - Business of the insured's employer or partner*YesNo3 - Hire or Reward*YesNoVehicle Usage - Commercial Vehicle1 - Carriage of goods(Other than Samples) in connection with own business or profession?*YesNo2 - Carriage of goods for Hire or Reward?*YesNo3 - Carriage of passengers for Hire and Reward?*YesNo4 - Specify any other purposes for which the vehicle will be used?*YesNoVehicle Usage - Motor Cycle1 - Will the motor cycle be ridden by the insured or by one named rider only?*YesNo2 - Will the motor cycle be used with a side-car attached?*YesNo3 - Specify any other purposes for which the motor cycle will be used?*YesNoDriver's declaration Have you or any of the driver above have: (If your answer is "Yes", Please provide details)1 - Any physical or mental infirmity or defective vision or hearing?*YesNo2 - Any traffic conviction in the last 3 years?*YesNo3 - Any accident for the past 3 years?*YesNo3 - Any drivers given demerits points?*YesNoInsurance History Has any insurance company or underwriter at any time in respect of motor insurance (new or renewal) in your name of any other person who, to your knowledge: (If your answer is "Yes", Please provide details)1 - Declined any proposal?*YesNo2 - Cancelled any policy of insurance?*YesNo3 - Imposed an excess or other special terms?*YesNo4 - Refused to renew any policy?*YesNoCAPTCHA
