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Name

First Name

Last Name

NRIC

Date of Birth

YYYY

Gender

Occupation

Contact No.

Country

(###)

###

####

Driving Experience (Years)

NCD (%)

Vehicle No.

Vehicle Make (Eg. Honda)

Vehicle Model (Eg. Freed)

Year of Make

Current Insurer

Current Premium

OPC

Have you made a claim or been in an accident before?

Do you have any demerit points?