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 PRIVATE CAR INSURANCE

Private Car Insurance
Region West Malaysia        East Malaysia
Use of Vehicle Individual Registration Company Registration
Insured's Name *
Insured's Age *
Insured's Occupation/Trade
HP No. * House No.
Office No. Fax No.
Email *
Vehicle Registration No. * Passengers Seatings
Make & Model of Vechicle *
Vehicle Sum Insured * Premium
Capacity Basic
Year of Manufacture *
Loading % Loading
NCD % NCD
Extra Coverage ( Tick if applicable ) Legend
AD Yes AD
LLP Yes LLP
LLAN Yes LLAN
SRCC Yes SRCC
FLOOD Yes FLOOD
CART Yes  CART
NCD Relief Yes NCD Relief
Extra Coverage ( Enter Sum Insured if applicable )
Windscreen Windscreen
CD / Cassette Player CD / Cassette Player
Gas Kit & Tank Gas Kit & Tank
Extra Coverage ( Enter a Number if applicable )
Additional Named Driver Additional Named Driver
( apart from first 2 drivers )
Gross Premium
Discount
  Sub-total Premium
Service Tax (5%)
Stamp Duty
 Total Premium payable
Prepared By
 
     
* are required fields.

Note: If your policy is accepted, a discount of 5% will be entitled for new customer and 10% discount for first renewal.
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