Is Owner driving? (If not driving, please fill in driver's details under Named Driver)
YesNo
Owner Name:

NRIC / ROC Number:

Date Of Birth (YYYY-MM-DD):

Gender:
MaleFemale
Marital Status:
MarriedSingle
Occupation / Industry:

Occupation Nature:
IndoorOutdoor
Driving Experience (In Years):

Any Named Driver(s)?
YesNo
If yes, please enter Named Driver(s) details:
Name: NRIC: Date of Birth: Gender: Marital Status: Occupation: Driving Experience (In Years): Relationship to Owner: Any accident(s) for the past 3 years?
Type of Purchase:
Brand New CarSecond-Hand CarExisting Car
Source of Purchase:
Authorised Local DistributorParallel Import Dealer
Car Make/Brand:

Car Model:

Car Engine Capacity (CC):

Manufacture Year:

Current Car Plate Number:

Previous Car Plate Number:

Current Insurer:

No Claim Discount (NCD) Upon Renewal:
—Please choose an option—0%10%20%30%40%50%
Coverage Type:
—Please choose an option—ComprehensiveThird Party, Fire & TheftThird Party Only
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:
Accident Date (DD-MM-YYYY): Total Claim Amount: Accident Description:
Existing Renewal Notice (Optional):

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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