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1920 00003W)
(a wholly-owned subsidiary of Great Eastern Holdings Limited)
1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: (65) 62482608 / 62482609 Fax: (65) 63273012 / 63273013 Website: www.Lifeisgreat.com.sg
PARTICULARS OF PROPOSER
AGENCY NAME / CODE REGISTRATION NO.
PARTICULARS OF VEHICLE
YEAR OF MANUFACTURE C.C. / TON
MAKE / MODEL
ENGINE NUMBER
CHASIS NUMBER
*NRIC / PP NO.
DATE OF BIRTH
NATIONALITY TYPE OF BODY: Please tick ( SALOON DEMRIT POINTS IN LAST 2 YRS ACCESSORIES: Please tick ( ) SPORTS RIMS OTHERS (SPECIFY: ) COUPE ) OTHERS (SPECIFY: )
OCCUPATION:
(*INDOOR / OUTDOOR)
AIR-CON
CD PLAYER
IS THE VEHICLE MODIFIED OR ALTERED FROM THE ORIGINAL VEHICLE SPECIFICATIONS? * YES / NO IF YES, PLASE GIVE COMPLETE DETAILS
ACCIDENTS /CLAIMS IN LAST 3 YEARS (YES/NO) YEAR OF ACCIDENT OWN DAMAGE CLAIM S$ 3RD PARTY CLAIM S$
PERIOD OF INSURANCE
FROM: ( am/pm) TO: (MID NIGHT)
TYPE OF COVER
COMPREHENSIVE COMPREHENSIVE DRIVE N SAVE 3RD PARTY ONLY
DATE OF BIRTH
*NRIC / PP NO.
OCCUPATION
DRIVING EXPERIENCE
OPTIONAL BENEFITS
AMT INSURED S$ BREAKAGE OF WINDSCREEN
ACCIDENTS /CLAIMS IN LAST 3 YEARS (YES/NO) YEAR OF ACCIDENT OWN DAMAGE CLAIM 3RDPARTY CLAIM
POLICY NO.
DECLARATION AND SIGNATURE *I/we hereby declare and agree to insure *my/our Motor *Vehicle/Cycle with THE OVERSEAS ASSURANCE CORPORATION LTD and *I/we agree to accept the Corporations Policy subject to the provisions and conditions of the Policy. *I/we hereby declare that the above mentioned Motor *Vehicle/Cycle is and will be kept in good condition. *I/we hereby warrant that all the answers given in this proposal are true and correct, that this Proposal and the Declaration shall form part of the contract between the Corporation and *myself/ourselves.
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Motor_Proposal_Form_17092007