Insurance Renewal

INSURANCE CLAIM FORM

Contact us:

DJ Koh
For Insurance Quote Email: dixionliu@gmail.com
Yin Wei

 

 

Insured / Owner Particulars

Insured/Owner Name (As per IC)(required):

IC No:(required)

Date of birth:(required)

Gender:(required)
 Male Female

Marital Status:

Occupation / Business:(required)

Licence Since:(required)

Contact No:(required)

Contact Email:(required)

(+)Name Driver

Vehicles Details

Registration No.(Vehicle No.):(required)

Vehicle Model

Type of Cover

Renewal NCD

Certificate of merit
 Not Sure No Yes (Customer will eligible with 5% discount of insurance payment)

Current Insurer

Finance Company

Parallel Imported
 No Yes

Off Peak Car
 No Yes

Claim Experience for past 3 years
 No YesIf yes, please specific claim amount SGD$

Expiry Date

Your Message

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