Capstone Insurance

Name (as in NRIC)

Marital Status

Nationality

Date of Birth (dd/mm/yyyy)

Driving Experience (Months, Years)

Sex

Contact No.

Make and model of vehicle

Year manufactured

Type of Cover

Engine Capacity (cc)

Current Insurance Company

No claim discount (NCD)

Any claims within the last 3 years (Y/N)

If yes, please state amount

Any modifications (Y/N)

If yes, please indicate

Year of Registration

Policy No.

Driving Experience (Months, Years)

Parallel Import

Off-peak vehicle

Sunroof/Moonroof

Vehicle type