VEHICLE INSURANCE / TAKAFUL QUOTATION APPLICATION FORM
In accordance with the Personal Data Protection Act 2010 (PDPA 2010), all your information is kept confidential and is only used for the purpose of processing Vehicle Insurance / Takaful Quotation application only. Selaras Akta Perlindungan Data Peribadi 2010 (PDPA 2010), semua maklumat anda dirahsiakan dan hanya digunakan untuk tujuan pemprosesan permohonan Sebut Harga Takaful Kenderaan sahaja.
Email
example@example.com
Name Of Vehicle Owner (As Per Registration Card - IC or SSM)
*
Nama Pemilik Kenderaan (Seperti Didaftarkan Dalam Geran - IC atau SSM)
Owner's IC No. or Company SSM No. As Registered
*
No IC Pemilik Kenderaan atau No SSM Syarikat Seperti Yang Didaftarkan
Phone Number *
*
Nombor Telefon
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Vehicle / Jenis Kenderaan
*
Car / Kereta
Motocycle / Motosikal
Commercial Vehicle / Kenderaan Perdagangan
Others / Lain-lain
Vehicle Registration No *
*
No Pendaftaran Kenderaan
Vehicle Brand & Model
*
Jenama dan Model Kenderaan
Second Driver Name (If Necessary) (Car Only)
Nama Pemandu Kedua (Jika Perlu) (Kereta Sahaja)
Vehicle Windscreen Coverage Value (Car Only) (If Necessary)
Jumlah Perlindungan Cermin Kenderaan (Jika Perlu) (Kereta Sahaja)
Additional Coverage (Tick If Necessary) / Perlindungan Tambahan (Tanda Jika Perlu)
Special Peril Coverage / Perlindungan Bencana Alam
All Driver / Semua Pemandu
Personal Accident Cover (PA) / Perlindungan Kemlangan Diri (PA)
Strike, Riot & Civil Commotion / Mogok, Kekacauan & Rusuhan
Legal Liability To Passenger / Liability Undang2 Terhadap Penumpang
Legal Liability Of Passenger / Liability Undang2 Oleh Penumpang
e-Hailing Coverage / Perlindungan e-Hailing
Vehicle Engine No. (Motorcycle Only)
Nombor Enjin Kenderaan (Motosikal Sahaja)
Vehicle Chassis No. (Motorcycle Only)
Nombor Chasis Kenderaan (Motosikal Sahaja)
Year Vehicle Made (Motorcycle Only)
Tahun Kenderaan Dibuat (Motosikal Sahaja)
Option To Include Road Tax Printing / Pilihan Untuk Cetakan Cukai Jalan
Print Road Tax & Send To My Address / Cetak Cukai Jalan & Hantar Ke Alamat Saya
I Will Pay Road Tax By My Own / Saya Akan Bayar Sendiri Cukai Jalan
Additional Remarks If Necessary
Butiran Tambahan Sila Nyatakan Jika Perlu
Take Photo OR Upload Documents Of Your Previous Insurance Cover Note / Registration Card (Optional)
Tangkap Gambar ATAU Muat Naik Dokumen Nota Perlindungan Insurans / Geran Kenderaan Anda (Jika Perlu)
Take Photo (Previous Cover Note Insurance / Registration Card)
File Upload
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Muat Naik Dokumen
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Introducer & Contact No (If Necessary)
Pengenal & No DiHubungi (Jika Perlu)
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