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AXA INSURANCE SINGAPORE PTE LTD 143 Cecil Street #01-01 GB Building Singapore 069542 Tel: 1800 880 4741 Fax: 6880 4740 Internet: http://www.axa.com.sg Co. Reg No. 196900406D
APPLICATION FORM
For non-SmartDrive Private Policies only
Motor Insurance
IMPORTANT NOTES 1. Under Section 25(5) of the Insurance Act Cap 142 or any subsequent amendment thereof, you are to disclose in this Application form, fully and faithfully, all the facts which you know or ought to know, otherwise the Policy issued may be void. 2. Please complete this form by answering carefully all questions. It is important that a complete answer be given to every question including dates where applicable in order to avoid unnecessary delay in the processing of this application. Any question not answered on this form will be taken as an answer in the negative.
Agent/ Account No. Policy No. Quotation No.
1) PROPOSER
PERSONAL PARTICULARS Full name of Proposer (As shown in NRIC/ Passport, please underline surname): t Mr t Ms t Mrs t Mdm t Dr
NRIC/ Passport No./ FIN : Address:
Date of birth (dd/mm/yyyy):
Race:
Postal code: Tel: (H) (Hp/ Pager): Sex : (Off): E-mail: Marital status : u Single
u Male u Female
u Married
Nationality :
u Singaporean u Others
Fax:
Occupation: PREVIOUS INSURER Previous Insurer: Policy No.: Vehicle No.: Policy expiry / Cancellation date: OTHER INFORMATION Off Peak Car:
Company’s name :
Sum Insured :
No Claim Discount entitlement: If NCB is 0%, please indicate reason: u First time owning a car u Claim made in last one year u Others
u Yes u No
) years
Usage of motor vehicle:
u Pleasure
u Business use
Parallel Imported Vehicle:
u Yes u No
u Weekend use u Others
Driving Experience: ( Safe driver’s incentive:
u Yes u No 2) VEHICLE DETAILS
Vehicle Type :
If Yes, please submit a copy of your Certificate of Merit with this Proposal. (Applicable for 30% to 50% NCD Only)
u
Private car
u
Commercial Vehicle
u
Motor Cycle
u
Others
Make & Model (include GTI, GL, etc): Engine No.: Year of registration: Body Type: Year of manufacture: Engine capacity:
Registration No.: Chassis No.: Seating capacity (excluding driver): Transmission:
u Saloon or Sedan u Coupe u Convertible u Multi-purpose Vehicle (MPV) u Others u Van u Lorry u Hatchback u Sports Utility Vehicle (SUV) u Yes u No u Yes u No u Yes u No
If Yes, please specify If Yes, please specify
u Automatic u Manual
Is the vehicle under financing/lease? Is the vehicle fitted with theft alarm? Has the vehicle been modified (other than factory fitted)?
If Yes, please specify with value
3) COVER DETAILS
Coverage:
A. SmartDrive Commercial policies only u Comprehensive u Third Party, Fire and Theft u Third Party only All SmartDrive Commercial policies are subject to use AXA Premium Workshops (APW) for accident repairs and a 10% discount is granted. To opt out of APW Scheme, you will forgo this discount. Please tick in the box if you wish to opt out u
B.
All other Motor policies u Comprehensive u Third party fire and theft
u Third party only
Sum Insured: ____________________________________________
Period of Insurance (dd/mm/yyyy): From To
Do you wish to insure COE and PARF value? (Applicable to Comprehensive and Third Party, Fire & Theft cover only)
4) NAMED DRIVER PARTICULARS
Name (as in NRIC, please underline surname) Relationship to Proposer Date of birth (dd/mm/yyyy) NRIC/ Passport no. / FIN Nationality Marital status Sex Race Driving Experience (years) Occupation Claim made, if any Named driver (1) t Mr t Ms t Mrs t Mdm t Dr Named driver (2) t Mr t Ms t Mrs t Mdm t Dr Named driver (3) t Mr t Ms t Mrs t Mdm t Dr
u Single u Married u Male u Female
u Single u Married u Male u Female
u Single u Married u Male u Female
5) OTHER INFORMATION RELATING TO DRIVER(S)
1. Have you had any motor insurance related claim over the last 3 years?
u Yes u No
If Yes, please specify:
Date of accident (dd/mm/yyyy)
Name of insurance company
Amount of claim
Details of claim (Own Damage/ Third Party/ Theft)
2. Have you or your named driver(s) been convicted of any driving offence in the past 3 years?
u Yes u No
If Yes, please specify:
3. Have you or your named driver(s) had your motor insurance terminated by any insurance company?
u Yes u No
If Yes, please specify:
4. Have you or your named driver(s) been given demerit points for traffic offences? No. of demerit points accumulated in the past 24 months: 5. Have you or your named driver(s) suffered any disease or infirmity that could impair the ability to drive?
u Yes u No u Yes u No
If Yes, please state driver:
If Yes, please specify:
6) DECLARATION
In accordance to Section 25(5) of the Insurance Act Cap 142 or any subsequent amendment thereof, you are to disclose in this Application form, fully and faithfully, all the facts which you know or ought to know, otherwise the policy issued may be void. 1. I hereby declare and agree to insure my motor vehicle with AXA Insurance Singapore Pte Ltd and I agree to accept the Company’s Policy subject to the terms, conditions and exceptions of the Policy. I hereby declare that the abovementioned Motor Vehicle is and will be kept in good condition. 2. I hereby warrant that all answers given in this proposal are true and correct and that this Proposal and Declaration shall form part of the contract between the Company and myself. 3. I hereby agree to give my consent for the Company to verify any given information with the relevant authority. 4. I acknowledge that should there be a change in any information provided, the premium quoted may be revised. I further acknowledge that the No Claim Discount is subject to confirmation by my current insurer and any difference in the No Claim Discount may affect the basic premium quoted.
_________________________________________ Signature of Proposer & Date
Notes: • Our liability does not commence until we have accepted this Proposal and the premium paid by the Proposer. • Your Policy carries a Premium Warranty Clause which requires the premium to be paid in full within 60 days failing which there would be no liability under the Policy.
FOR OFFICIAL USE ONLY
Total Premium (Including GST) : S$ Date (dd/mm/yyyy) : Staff Name & Signature :
MTR/FM3/0208