Company Name:

ROC Number:

Address:

Nature of Business / Business Industry:

Current Insurer:

Coverage Period-From (YYYY-MM-DD):

Coverage Period-To (YYYY-MM-DD):

Any Claim(s) for the past 3 years?
YesNo
If yes, please enter accident(s)/claim(s) details:

Existing Renewal Notice (Optional):

A. Permit Type:
—Please choose an option—Work PermitS-Pass
A. No. Of Worker(s):

Workers' Name List (Optional):

B. Permit Type:
—Please choose an option—Work PermitS-Pass
B. No. Of Worker(s):

Workers' Name List (Optional):

Campaign:
(Name of Charity Organisation OR Customized Scheme)
Contact Personnel:

Contact Number:

Email:

Prefer to contact via:
Phone CallSMSE-Mail

By submitting this request, I understand that all information provided above are correct and PERLE 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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