Name: *

NRIC / FIN: *

Date of Birth(DD/MM/YY): *

Gender: *

MaleFemale

Marital Status: *

MarriedSingle

Occupation: *

Years of License Obtained:
Less than 1 year1 year & above2 years & above3 years & above4 years & above5 years & above6 years & above7 years & above8 years & above9 years & above10 years & above11 years & above12 years & above13 years & above14 years & above15 years & above

NCD: *
NIL10%20%30%40%50%

Current Insurer: *

Vehicle No. : *

Claim Experience: *

YesNo

Contact No. :

Your Email (required)

Special Instructions:

By submitting this form, you agree that we may collect, use and disclose your personal data, as provided in this application form for the following purposes in accordance with the Personal Data Protection Act 2012:
(a) to provide you with industrial relations related services; and
(b) to assist you with your enquiries via mail, electronic mail, telephone (call or SMS-Text).
We maintain appropriate security safeguards and practices to protect your Personal Data unauthorised access, collection, use, disclosure, copying, modification disposal or similar risks, in accordance with applicable laws.