Insurance Quotation Request

1 Submitting as

Dealer / Company Name

Dealer / Agent Code

Salesman

Mobile

Submitted By

2 What would you like to insure?

Insurance type

3 Policy holder

Full Name

NRIC / FIN

Gender

Date of Birth

Marital Status

Mobile

Resident Status

Nationality

Occupation

Company Name

UEN

Contact Person

Office Number

Mobile

Mailing Address Postal Code

Block No/Street

Floor

Unit

Country Postal

Driving Licence

Add Licence

Driving Licence Class

Driving Licence Pass Date

4 Details

Vehicle

Vehicle Condition

Used New

Vehicle registration no.

Access Code

Make

Model

Year of Manufacture

Original Registration Date

Vehicle Scheme

Named Driver

Main driver

Additional named drivers

Destination

Region

Trip Start

Trip End

Plan Tier

Policy Period

Max days / Trip

Organiser

No. of Travellers

Student

Institution / Country

Course Duration

Course Start

Cover Type

Group Policy Holder

UEN

No. of Insured Lives

Average Age

Plan Tier

Occupational Class

Sum Assured / Head

Employer

UEN

No. of Workers

Work Permit Type

Owner

Pet Name

Species / Breed

Age

Microchip No.

Insured persons

Are you one of the travellers?

Person

Insured / company name

Home type

Risk address

Construction type

Occupancy / usage

Premises address

Contents / stock

Stock value

Trade / process

Building sum insured

Contents sum insured

Business interruption

Helper Full Name

FIN / Work Permit No.

Work Permit Status / Type

Date of Birth

Gender

Marital Status

Nationality / Country of Origin

Passport No.

Maid Type

Arrival Date

Transfer Date

Work Permit Expiry Date

Start Date of Coverage

Employment Duration / Policy Term

Principal / Employer / Contractor

UEN

Worker FIN

Bond amount

Contract / Project

Contract value

Bond %

Licence

Town council / HDB

Guarantee amount

Obligee / Beneficiary

Same as Policy Holder?

Insured / Organiser

UEN

Trade / Business / Activity / Profession

No. of Employees

Estimated Annual Wages

Premises

Event

Event Date

Expected Attendance

Product

Markets / Territory

Annual Turnover

Annual Fee Income

Retroactive Date

Listed / Private

No. of Directors

Total Assets

Venue

Principal / Insured

Project

Contract value

Project Period

Plant Erected

Erection Value

Testing Period

Equipment

Make / Model

Sum insured

Location

Site

Insured

Cargo

Voyage departure

Voyage destination

Conveyance

Sum insured / shipment

5 Documents & notes

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