Insurance Renewal Form

Insured / Owner Particulars

* Insured Name:

* I/C No.:

* Date of Birth:

Gender:
 Male Female

Marital Status:
 Single Married Other

* Occupation / Business:

* License Since:

** Contact No.:

Named Driver Particulars:

* Named Driver:
 No Yes

* Name Driver:

* I/C No.:

* Date of Birth:

Relationship:

(with owner)

* Gender:
 Male Female

* Marital Status:
 Single Married Other

* Occupation / Business:

* License Since:

Vehicle's Details

* Vehicle Model:

* Registration No. (Vehicle No.):

Type of Cover:

* Renewal NCB:

* Certificate of Merit:
 No Yes (Customer will be eligible with 5% discount of insurance payment)

* Current Insurer:

* Finance Company:

* Parallel Imported:
 No Yes

* Off Peak Car:
 No Yes