Full Name (as per IC) / Company Name:

NRIC Number / Company Registration Number:

Contact Number

Email Address

Vehicle Number

Vehicle Make & Model

Year of Manufacture

Engine Capacity (CC)

Permit Type A / C (applicable for commercial vehicle only) Permit Type A / C (applicable for commercial vehicle only)Type AType C

Sum Insured Amount (RM)

Windscreen Sum Insured Amount

Named Driver / All Drivers? Named Driver / All Drivers?Named DriverAll Drivers

Loan/Lease Status: Is it under hire purchase or fully owned?

Full Name (as per passport)

Passport Number

NRIC Number

Date Of Birth

Contact Number

Email Address

Travel Destination(s)

Departure & Return Date (Range)

Type of Trip Type of Trip *SingleAnnual Multi-Trip

Purpose of Travel Purpose of Travel *LeasureBusinessOthers

Are you travelling alone or with family/group? Are you travelling alone or with family/group? *AloneWith Familiy/Grpup

Do you require COVID-19 coverage? Do you require COVID-19 coverage? *YesNo

Any pre-existing medical conditions? If yes, please state it.

Coverage for high-risk activities (e.g., skiing, diving, high altitude climbing)? Coverage for high-risk activities (e.g., skiing, diving, high altitude climbing)? *YesNo

Full Name (as per IC)

NRIC Number

Date Of Birth

Contact Number

Email Address

Gender Gender *MaleFemale

Current Occupation

Are you a smoker? Are you a smoker? *YesNo

Do you have any existing medical insurance?

Any pre-existing medical conditions? (e.g., diabetes, hypertension)

Are you currently under any medication or treatment?

Annual Budget? (Optional but useful)