Bingo Form – bingo

Your data will be used to generate an insurance quote

Email Address *

Mobile *

Personal Information

How do You want to provide data? *Uploading FilesManual Input

Upload Identity

NRIC - Front Side *

No file chosen

NRIC - Back Side

No file chosen

Marital Status *SingleMarried

Upload Driver's License

Driver's License - Front Side *

No file chosen

Driver's License - Back Side

No file chosen

Total Demerits Points

Input Owner's Identity

NRIC Number *

Full Name *

Date of Birth *

Day

Month

Year

Gender *MaleFemale

Marital Status *SingleMarried

Address

Postal Code

Input Driver's License

Date of Issued *

Day

Month

Year

Date of Passed *

Day

Month

Year

Total Demerits Points

Renewal Notice?

Do you have an insurance renewal notice? *Yes, I want to upload renewal notice fileNo, I will perform manual input

Renewal notice file *

No file chosen

Insurance

NCD Upon Renewal (%) *

Preferred Excess ($) *

Policy Start Date *

Day

Month

Year

Type of Cover *ComprehensiveTPFT - Third Party, Fire & TheftTPO - Third Party Only

Number of At Fault Claims In The Past 3 Years *

Desired Optional Benefit

Vehicle

Upload Log Card Photo

No file chosen

Vehicle Plate No. *

Chassis No. *

Engine No. *

Date of Registration *

Day

Month

Year

Vehicle Make *

Vehicle Model *

Engine Capacity *

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