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Owner Name: |
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Citizenship: |
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Date Of Birth: |
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NRIC / FIN No.: |
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Gender: |
Male Female |
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Marital Status : |
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Occupation: |
Indoor Outdoor
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Coverage Period : |
to |
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License Date: |
(If no license, please indicate 8 zeros.) |
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Car Plate No. : |
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Current Insurer: |
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Coverage : |
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NCD Entitled: |
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Any Offence Free Discount? |
Yes No |
Check here |
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Claims in last 3 years? : |
Yes No |
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(If yes, please state in the box below)
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Any Additional Information :
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Contact Person: |
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Mobile : |
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Email : |
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Prefer to contact via :Phone Call E-Mail SMS
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By submitting this request, I understand that all information provided above are correct and Motorance is given the permission to use my information. I acknowledge having read through the Privacy Policy and consent to use my information for the purpose of obtaining insurance quotes and to be contacted for quotation updates. Where the data provided is not mine, I confirm that I have the consent of the owner to provide such data.
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