Type of Quotation:* SelectPrivate Car (Individual)Private Car (Company)Commercial Vehicle
Vehicle Registration No.*
Vehicle Make / Model*
Transmission Type* [radio* transmission-type "Auto" "Manual"]
Vehicle Scheme* [radio* vehicle-scheme "Normal" "Off Peak"]
Type of Coverage* Select CoverageComprehensiveThird Party, Fire and TheftThird Party Only
No Claims Discount (NCD)* Select NCDNIL10%20%30%40%50%
Current Insurance Company*
Current Insurer Renewal Premium*
Details of Insured - Individual* [radio* insured-individual "Applicable" "Not Applicable"]
ID Type Select ID TypeNRIC PinkNRIC BlueEmployment PassS PassWork PermitForeign Passport
NRIC / FIN / Passport No.
Full Name (As shown in NRIC/FIN/Passport)
Nationality
Date of Birth (dd-mm-yyyy)
Gender Select GenderMaleFemale
Marital Status Select Marital StatusSingleMarried
Occupation
Working Environment Select Work EnvironmentIndoorOutdoorIndoor / Outdoor
Insured Driving YesNo
Driving Pass Date (dd-mm-yyyy) (Applicable if Insured Driving)
Details of Insured - Company* [radio* insured-company "Applicable" "Not Applicable"]
Company Name
ROC Number
Nature of Business
Contact / Mobile No.
E-mail
Applicable ApplicableNot Applicable
Full Name (As shown in NRIC/FIN/Passport)*
Driving Pass Date (dd-mm-yyyy)
Relationship with Insured
Marital Status* Select Marital StatusSingleMarriedDivorceeWidow/er
Number of Claims in the last 3 Years (vehicle, insured and named driver/s)*
Date of accident*
Details of Claim*
Amount of Claim*
By submitting this form, I hereby consent that my personal data be disclosed by Parkway Insurance Agency Pte Ltd to its third-party service providers, agents, or insurers for the purpose of obtaining motor insurance quotations. I also agree to receive calls, SMS, and emails from Parkway Insurance Agency Pte Ltd & their respective partners.
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