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Vehicle Status

Car Plate No.

Vehicle Make:

Vehicle Model:

Body Type:

Engine Capacity:

cc

Manufacture Year:

Registration Date

Parallel Import:

Off-Peak Car:

CNG Car:

Car Owner Details

Car Owner Has Valid Driving Licence?

YesNo

Car Owner's Name:

Car Owner's NRIC:

Birth Date:

Nationality:

Citizenship:

Gender:

Marital Status:

Job Nature:

Job Title:

License Pass Date:

Mobile Number:

Email Address:

Please Provide MAIN DRIVER Details

Name

NRIC:

Birth Date:

Relationship:

Gender

Marital Status:

Occupation:

License Pass Date:

Claims:

S$

(Last 3 Yrs)

Insurance Details

Coverage:

Existing Insurer:

Renewal Premium:

S$

NCD Upon Renewal:

Renewal Date:

Claims (Last 3 Yrs):

NoYes

No. of Claims:

(In Last 3 Yrs)

Please Provide Latest Claim Details

Latest Claim Date:

Own Damage Claim:

S$

Third Party Claim:

S$

Please Provide Earlier Claim Details

Earlier Claim Date:

Own Damage Claim:

S$

Third Party Claim:

S$

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