Private Car Form - Insured United

Private car
Name of Proposer/Company*

NRIC/FIN No*

Mailing Address*

Contact No*

Occupation*

Gender*

Date of Birth*

Marital Status*

Years of Driving Experience

Any Claims in past 3 years?*

Particulars of Additional Driver(s)
Name of Driver(s)

NRIC/FIN No

Date of Birth

Gender

Relationship to Proposer

Any Claims in past 3 years?

Years of Driving Experience

Occupation

Details of Vehicle
Off-Peak Car?*

Registration No.(Car Plate Number)*

Make and Model*

Engine Capacity*

Chassis No*

Engine No*

Year of Manufacture/Year of Registration*

No Claim Discount (NCD)/ Reasons if NCD is NIL*

NCD Protector*

Current Insurance Company*

Date of Current Policy Expiry/ Cancellation*