e- INSURANCE APPLICATION FORM | Singer Malaysia

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Home» e- INSURANCE APPLICATION FORM

e- INSURANCE APPLICATION FORM

* All details are compulsory and necessary to be filled

A. INSURED PARTICULARS

Name *

IC Number

Passport/Others Number If any

Gender *

Race *

Malay

Chinese

Indian

Other

Marital Status *

Single

Married

Email *

Occupation *

Phone (House)

Phone (Office)

Phone (Mobile) *

Address *

Post Code *

Town *

State *

B. VEHICLE PARTICULARS

Vehicle Type *

Motorcar

Motorcycle

Insurance Type *

Single Rider

All Rider

Vehicle Registration No *

Engine No *

Chassis No *

Coverage *

Comprehensive

Third Party, Fire & Theft

Brand & Model *

Engine Capacity *

Year of Manufactured *

Purchase Price * RM

Hire Purchase Company If any

C. PREVIOUS / CURRENT INSURANCE PARTICULARS

Insurance Company *

Policy No *

NCD on Policy (%) * %

Period of Insurance

Year

Month

Day

To

Year

Month

Day

D. RENEWAL DETAILS

Preferred Insurance Company *

Berjaya Sompo

Pacific & Orient

Policy Commencement Date *

Year

Month

Day

Policy Expiry Date *

Year

Month

Day

Current NCD (%) (If know) %

I declare that the information provided in this application is true

I agree and authorise SINGER to utilise the information provided in this application for the purpose of providing fair evaluation of the premium applied by me

I have read and agreed with the Terms & Conditions

What code is in the image? *

Enter the characters shown in the image.

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