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2/18/08
2:16:34 PM
Underwritten by
American Home Assurance Company, Singapore (AHAC) is a member company of American International Group, Inc (AIG). Incorporated in the United States with liability limited. American Home Assurance Company Singapore
2/13/08
4:31:34 PM
Statement pursuant to the Insurance Act or any amendments thereof: You are to disclose in this Proposal Form, fully and faithfully, all the facts which you know or ought to know, otherwise the Policy issued may be void.
To Producer / Sub-code From Contact No Tel No Fax No Head Office 1 800 419 3000 6835 7408 Alexandra 6373 8023 6276 4846 Changi 6340 0438 6348 2790 Tampines 6587 7231 6787 3645
10 Days Loss of Use Benefit 1200cc 1300cc (Manual) @ S$72.76 (Inclusive of 7% GST) Fixtures and Accessories (please provide details and attach invoice) NRIC/FIN/ROC No* Others 1500cc 1600cc @ S$94.16 (Inclusive of 7% GST) 1800cc 2000cc @ S$115.56 (Inclusive of 7% GST)
Yes
No
Residential (Block/House No) Address (Street Name) (Building Name) (Singapore) Contact Details (Mobile) (Residential) (Email) Name of Employer Occupation/ Nature of Business
(Level-Unit No)
Passport No.
PAYMENT MODE
Date of Birth Nationality
Cash
Cheque. Please make cheque payable to: American Home Assurance Company
Bank
Cheque No
Singaporean Others:
Permanent Resident
I/We hereby authorise American Home Assurance Company, Singapore (AHAC) to charge the stated annual premium to the following credit card. Where a third party credit card is used, I/we declare that the cardholder has authorised and consented to its use. Credit Card (MasterCard/Visa/American Express) [Please tick () accordingly] 0% Interest Installment Payment with DBS/POSB credit card*** 12 Monthly 0% Interest Installments with DBS/POSB credit card*** 6 Monthly 0% Interest Installments with DBS/POSB credit card*** Name as on card: Card No: Card Expiry Date: Amount:
(Office) (Fax)
Male Single
(please specify)
(Mths)
(if unemployed, please provide name of previous employer and year of last employment)
M
S$
Job Nature
Mostly Indoor
Mostly Outdoor
* Delete where applicable.
(If you are an American Express Cardholder, please fill up your card number from the second box)
*** Not applicable for DBS Corporate Card and DBS/AMEX Affinity Card.
DECLARATIONS
Please tick () below where applicable. Otherwise, declarations will be taken as 'NO'.
At fault claims experience in past 3 years (please provide details below) Date of accident (dd/mm/yy) Description of accident Amount of claim ($) Type of claim
(Own Damage/Third Party/Theft/Bodily Injury)
Record of revoked/endorsed driving license NCD (%) COM** (5%) Yes (Please attach COM from Traffic Police)
If NCD is nil or 10% with no claims experience, please provide the reason:
** Subject to 30% NCD or more with submission of the Certificate of Merit (COM) from Traffic Police. The COM can be printed from eCitizen website http://www.ecitizen.gov.sg
Signature: Body Type Saloon SUV Registration No Insurance with COE/PARF?*** Off-Peak Car? Yes Yes No No Coupe Others
(please specify)
D D M M Y Y
to midnight of
D D M M Y Y
Year of Registration Engine Capacity
MPV
Name of Proposer:
Less: 5% Certificate of Merit Discount Less: Off-Peak Car Discount Add: Fixtures and Accessories
S$
*** When insuring without COE/PARF, please inform the financier(s) if vehicle financing is involved. In this instance, in the event of total loss, the Insured will recover the residual value of the COE/PARF from LTA and undertake the financial exposure when disposing the COE/PARF Refund Certificate in the open market.
35 years old & above age condition 40 years old & above age condition
American Home Assurance Company, Singapore (AHAC) is a member company of American International Group, Inc (AIG). Incorporated in the United States with liability limited. American Home Assurance Company Singapore