Autosaver - Auto Car Care

Insurance Registration Form

Please fill in the form below to register for a free car insurance quotation:

Personal Information

Full Name (As in NRIC/Passport)

NRIC/Passport No.

Contact Number

Occupation

Occupation Location

Indoor Outdoor

Gender

Male Female

Marital Status

Single Married Divorced

Date of Birth

(DD/MM/YYYY)

Date of Obtaining Driving License

(DD/MM/YYYY)

Vehicle Information

Car Plate No.

Vehicle Scheme Type

Normal Off Peak

Parallel Import

Yes No

Type of Vehicle

Year of Registration

(e.g. 2005)

Vehicle Make

(e.g. Mitsubishi)

Vehicle Model

(e.g. Lancer 1.6A)

Insurance Information

Insurance Expiry Date

(DD/MM/YYYY)

Current Insurer

Current Premium

($)

Type of Coverage Needed

NCD Upon Renewal

Additional Driver(s)

Any additional Driver?

Yes No


Additional Driver 1 Name
NRIC/Passport No.
Occupation
Occupation Location	Indoor Outdoor
Gender	Male Female
Marital Status	Single Married Divorced
Date of Birth	(DD/MM/YYYY)
Date of Obtaining Driving License	(DD/MM/YYYY)

Additional Driver 2 Name
NRIC/Passport No.
Occupation
Occupation Location	Indoor Outdoor
Gender	Male Female
Marital Status	Single Married Divorced
Date of Birth	(DD/MM/YYYY)
Date of Obtaining Driving License	(DD/MM/YYYY)

Claim History

Any claims experience
in the past 3 years?

Yes No


Number of Claims (past 3 years)	1 2 3 More than 3
Date of Last Accident	(DD/MM/YYYY)
Nature of Last Claim	Own Damage 3rd Party Others
Status of Last Claim	Closed Pending Others
Amount of Last Claim	($)
Last Accident Description

Others

Remarks

Hire Purchase Company (If any)

Please tick on the box

Outlet Location
	48 Toh Guan Road East #01-101 Enterprise Hub Singapore 608586 Tel: 6515 9750

	160 Sin Ming Drive #04-21 Sin Ming Auto City Singapore 575722 Tel: 6266 2368