Cowell Insurance Pte Ltd - Request For Insurance Quotation

Request for Insurance Quotation ::

Important Notice:

Statement Pursuant to Section 24(4) of the Insurance Act (Cap. 142 (Revised Edition1985)) - You are to disclose in this form fully and faithfully all the facts which you know or ought to know, otherwise the policy hereunder may be void.

The insurance will not be in force until the application and premium have been received and accepted by the company.

Note: All 'motor-related' fields are required before submission can be processed.

Name of Insured (as in NRIC):

Occupation:

Driving Experience:

Sex:

Status:

Date of Birth:

yyyy

Vehicle No:

Make & Model of Vehicle:

cc:

Year of Registration:

Current Insurance Co:

Policy No:

No Claim Discount:

Any claims within past 2 years?

If 'yes', please state amount

Parallel Import?

(Please fill in 'NA' where applicable)

Please note that this is an online request for a quotation. Kindly provide us with your full contact details and we will respond as soon as possible.

* Name (in Full):

* Email:

Mobile No:

Office No:

* Required Field

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	159 Kampong Ampat, #05-03, K A Place, Singapore 368328 Ph: 6339.2592 \| Fax: 6338.9908 \| Email: contactus@cowell.com.sg
Copyright © 2007 Cowell Insurance Pte Ltd. All Rights Reserved.