MarineLife Singapore

PARTICULARS OF PROPOSER (Registered Owner of Vehicle)

Name of Proposer/ Business Name:

Gender:

NRIC/ Passport/ ROC No:

Date of Birth:

Nationality:

Marital Status:

Date of Passing (DD/MM/YYYY):

Driving Experience (Years):

Address:

TEL/ Mobile No:

Email:

Occupation/ Business Trade:

Proposer Driving the Vehicle?

TYPE OF COVER REQUIRED

Coverage Required:

Preferred Workshop Scheme:

NCD Protector - Only if NCD is 50%
( Private Vehicle )

Period of insurance:
(DD/MM/YYYY)

Insure with COE/ PARF?

VEHICLE & CURRENT INSURANCE DETAILS

Current Renewal Premium & Company:

Financing Bank/Company:

Company registered car:

Vehicle No:

Warranty:

Off-Peak?

Year of Manufacture:

Year of Registration:

Parallel Import:

Make:

Model:

Body Type:

Engine Capacity:

Any Modifications:

Road Tax:

Hybrid/CNG:

For Commercial Vehicle

Tonnage:

Laden/ Unladen:

Current Insurer:

NCD %(on renewal):

Safe Driver Discount:

If NCD is 0% (Private Car), please state:

DETAILS OF ADDITIONAL DRIVER OR MAIN DRIVER

Include details if more than 1 driver

Full Name:

NRIC/Passport No:

Date of Birth (DD/MM/YYYY):

Marital Status:

Driving Experience (Years):

Occupation:

Relationship with proposer:

IMPORTANT QUESTIONS

Do you or your authorised driver suffer from any disease or physical impairment which could affect the ability to drive:

Have you or your authorised driver been given/ accumulated demerit points for traffic offences during the last 24 months:
(parking offences excepted)

Any claim in the last 3 years?

CLAIMS HISTORY OF PROPOSER / ADDITIONAL / MAIN DRIVER IN LAST 3 YEARS (If any)

Name of driver:

Status (eg: pending, closed, etc)

Date of Accident (DD/MM/YY):

Total Amt Claimed: $

Insure:

Claim Details: