1. Coverage and Period of Insurance

Choice of Coverage
—Please choose an option—ComprehensiveThird Party Fire & TheftThird Party

Period of Insurance*

to*

2. Vehicle Details

Vehicle Number*

Parallel Import*
—Please choose an option—YesNo

Modified Vehicle*
—Please choose an option—YesNo

Vehicle Make and Model*

Off-peak car?*
—Please choose an option—YesNo

Finance Company*

Sum Insured (Optional)

3. Proposer (Vehicle Registered Owner Only)

Full Name (As per NRIC or ROC)*

Date of Birth*

NRIC/ROC Number*

Gender*
—Please choose an option—MaleFemale

Occupation*

Marital Status*
—Please choose an option—MarriedSingleDivorce

Licence Passing Date*

Email*

Contact Number*

No Claim Discount (NCD)*
0%10%20%30%40%50%

Address*

Previous Insurer*
—Please choose an option—AIG Asia Pacific Private LimitedAllianz Insurance Company of Singapore Private LimitedAviva Ltd.Axa Insurance Singapore Private LimitedChina Taiping Insurance (Singapore) Private LimitedDirect Asia Insurance (Singapore) Private LimitedEQ Insurance Company LimitedErgo Insurance Pte. Ltd.Etiqa Insurance Berhad, Singapore BranchFirst Capital Insurance LimitedHL Assurance Private Limited (a member of Hong Leong Group)India International Insurance Private LimitedLiberty Insurance Pte Ltd C/o Liberty MutualLonpac Insurance BerhadMitsui Sumitomo Insurance (Singapore) Private LimitedMSIG Insurance (Singapore) Private LimitedOverseas Assurance Corporation LtdOverseas Union Insurance LimitedQBE Insurance International LimitedRoyal and Sun Alliance Insurance (Singapore) LimitedShenton Insurance Private LimitedTenet Sompo Insurance Private LIimitedTokio Marine Insurance SingaporeUnited Overseas Insurance LimitedZurich Insurance (Singapore)Others

4. Claim Experience

Claims in the past 3 years?*
—Please choose an option—YesNo

Suspension of Driving*
—Please choose an option—YesNo

5. Additional Named Driver

Additional Named Driver*
NoYes

Named Driver Details 1

Salutation*

NRIC/FIN No.*

Driver Name*

Date of Birth*

Gender*
—Please choose an option—MaleFemale

Marital Status*
—Please choose an option—MarriedSingleDivorce

Nationality*
—Please choose an option—SingaporeanMalaysian

Driver's Age*

Driving Exp.(Years)*

Driving License Pass Date(For SG/MY)*

Add Named Driver*
NoYes

Named Driver Details 2

Salutation*

NRIC/FIN No.*

Driver Name*

Date of Birth*

Gender*
—Please choose an option—MaleFemale

Marital Status*
—Please choose an option—MarriedSingleDivorce

Nationality*
—Please choose an option—SingaporeanMalaysian

Driver's Age*

Driving Exp.(Years)*

Driving License Pass Date(For SG/MY)*

Add Named Driver*
NoYes

Named Driver Details 3

Salutation*

NRIC/FIN No.*

Driver Name*

Date of Birth*

Gender*
—Please choose an option—MaleFemale

Marital Status*
—Please choose an option—MarriedSingleDivorce

Nationality*
—Please choose an option—SingaporeanMalaysian

Driver's Age*

Driving Exp.(Years)*

Driving License Pass Date(For SG/MY)*

Remarks

(If attaching more than 1 file, zip it before attaching)

I/we hereby understand that I/we need to disclose our personal data in order for Winner Consultancy Pte Ltd to generate a quotation for me/us. I/we agree that my/our declaration and disclosures herein are truthful and to the best of my knowledge. I/we agree and understand that accuracy of quotation premium is solely reliant on information provided by me/we only.