Motor Proposal Form - Private Motor Car _Revised Ver Apr 09_ by fjzhangweiyun

VIEWS: 3 PAGES: 2

									                                      MOTOR INSURANCE QUOTATION AND PROPOSAL FORM - PRIVATE MOTOR CAR
                                                                                            Date:
Name of Proposer :                                                                                                 Vehicle No.
Thank you for your interest in our motor insurance. We are pleased to provide you the following quotation:

Type of Cover
Period of Insurance
                                                                  Approved Workshop Plan                           Non-Approved Workshop Plan

Basic Premium
No Claim Discount
Safe Driver Discount
Additional / Discount Premium
Premium before GST
GST - 7%
Premium Payable Inclusive of GST
Policy Excess
Loss of Use Cover @ $40 Per Day (Days)                                                                       Additional Premium $               -
Original Excess                                                                                    Additional/Discount Premium $                -

                                                                             Other Terms
              . The policy excess will be waived for the first claim in the policy year if you enjoy 40% NCD and above and the vehicle is driven by you or a
                Named Driver at the time of the accident provided the accident repairs are carried out at one of our Approved Workshops. The waiver of
                excess is applicable to the standard excess and not to the additional or buy up excess.
              .
                If your vehicle is registered under a company's name and is driven by a person who is under 26 years old and/or has 2 years or less driving
                experience at the time of accident, an additional excess of S$3,500.00 will apply.
              .
                If your vehicle is driven by an unnamed driver at the time of accident, an additional excess of S$500.00 will apply. However, if the unnamed
                driver is under 26 years old and/or has 2 years or less driving experience, the additional excess will be S$3,500.00.
              .
                All windscreen replacements must be carried out at any of our approved workshops, even if the insured vehicle is under manufacturer's
                warranty or is insured under the Non-Approved Workshop Plan.
              .
                For parallel import cars, all accident repairs must be carried out at one of our approved workshops.
                                                                        IMPORTANT NOTES
              . This quotation is valid for 7 days from date
              .
                The quotation is based on the information printed herein. Please check that the printed information is correct. We reserve all rights to revise
                the premium and terms of the quotation if any of the information is not correct. If any of the information is not correct, please contact the
                servicing agent or call us at 6325 0440 to reconfirm the quotation or obtain a revised quotation.
              .
                If the information printed therein is correct and you accept our quotation, please complete and sign the form below.
              . This quotation cum proposal form is not an insurance policy. The specific terms, conditions and exclusions applicable to the insurance are
                contained in the policy which will be issued to you upon acceptance of your application. A copy of the specimen policy can be made available
                to you upon request.
              . Under the insurance Act, you must tell us all the facts that you know, or ought to know, about the risk that you are proposing. If you do not
                tell us everything that is relevant or if you mislead us, we may refuse to pay a claim or part of it, or cancel the policy.
              . Policy is subject to "Premium Before Cover Warranty".
                Please ensure premium payment is made promptly to ensure your insurance is valid as it is an offence under the Law not to have valid
                insurance covering your vehicle.
                                                              DETAILS OF REGISTERED OWNER
Name
Address                                                                                                   Tel (Home)
                                                                                                          Tel (Office)
                                                                                                          Handphone/Pager
Email                                                                                                     Fax
Name of Employer
Nature of Business
Occupation
NRIC/Passport/ROC No.                                Date of Birth (or photocopy of NRIC/Passport)                                  Age
Nationality                                          Marital Status   S/M*                                Sex      M/F*
Driving Licence Pass Date (please provide a photocopy of the Driving Licence)                             Demerit Points
* Delete where not applicable
* Delete where not applicable                                                                                                                          (cont'd)
                                                             DETAILS OF INSURANCE REQUIRED
Type of Cover

                                                                                                                                                             Page 1 of 2
                                        MOTOR INSURANCE QUOTATION AND PROPOSAL FORM - PRIVATE MOTOR CAR
Insurance Plan                Approved Workshop Plan / Non-Approved Workshop Plan *
Period of Insurance
                                                                           DETAILS OF VEHICLE
Vehicle Type                                            Make                                                  Model
Registration No.                                        Engine No.                                            Chassis No.
Seating Capacity                                        Engine Capacity                                       Vehicle Usage
Year of Manufacture                                     Registration Yr.                                      Hire Purchase Co.
                                                                   DETAILS OF PAST INSURANCE
Name of Last Insurer
Policy No.                                                                                    Vehicle No.
NCD                                                                                           No. of Claim Over Last 1 Year
Total Claim Amount Over Last 1 Year                                                           No. of Claim Over Last 2 Years
Total Claim Amount Over Last 2 Years                                                          No. of Claim Over Last 3 Years
Total Claim Amount Over Last 3 Years                                                          Was Renewal Declined by Insurer?
                                           DETAILS OF NAMED DRIVERS OTHER THAN THE OWNER (MAXIMUM OF 3)
                                                                                                              Driving Licence Pass
                                                                           Date of Birth                      Date (please provide a
                                                                           (or photocopy of                   photocopy of the Driving                   Demerit
Name                                                    Sex     Age        NRIC/Passport)     Occupation      Licence)                 Marital Status    Points
1)
2)
3)
                                                                DRIVING AND INSURANCE HISTORY
Do you or any of the named drivers have:
              .   any physical or mental infirmity or defective vision or hearing?                                                                       Yes / No
              .   any traffic conviction or suspension in the last 3 years?                                                                              Yes / No
              .   any accident in the last 3 years? If yes, please provide details:                                                                      Yes / No
                  ______________________________________________________________________________________________
              .   any records of drink driving or accidents resulting in serious injuries or death? If yes, please provide details:                      Yes / No
                  ______________________________________________________________________________________________
Has any insurance company, in respect of motor insurance (new or renewal) for you or any of the named drivers:
              .   declined any proposal?                                                                                                                 Yes / No
              .   cancelled any policy?                                                                                                                  Yes / No
              .   imposed an excess or other special terms?                                                                                              Yes / No
              .   refused to renew any policy?                                                                                                           Yes / No
                                                               DECLARATION AND AUTHORISATION
     I declare that:
              .   The information shown in this application form and any other attaching documents are correct and complete.
              .   I agree to accept the policy terms and that this proposal will form part of the contract between us.
              .   I will keep the vehicle in good condition.
              .   I will pay you any additional premium if the NCD confirmed by my previous insurer is lesser than what I have disclosed.
              .   I agree that I will be responsible for the policy excess and the additional policy excess (where applicable) as indicated in the quotation
                  provided.

     I further authorise you to give to or obtain from any other insurers, the Traffic Police and the Land Transport Authority and them to disclose,
     any necessary information in connection with this insurance or other insurance held by me in the past. I further understand that the
     insurance will not be in force until this proposal has been accepted by the company and I have paid the premium.

     Signature of Proposal (For Individual)                                                    Signature of Authorised Person & Company Stamp
                                                                                               (For Company)



     Date:                                                                                     Date:

 Agent Name                                                                                   Agent Code

                                                                      FOR OFFICAL USE ONLY
 Approved By                                                                                  Date:




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