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Insured Name

ROC/NRIC No

Contact No

Address

Vehicle No.

Make

Renewal NCD

Model

Exisiting Insurer

Year of Manufacture

Previuos Registration No

Original Reg. Date

Yr Made / Date of Reg

Type of Cover

Remarks

	Distributor’s Workshop	Any Workshop	Authorised Workshop	Remarks

China Taiping
Excess

NTUC
Excess

Lonpac
Excess

ETIQA
Excess

ERGO
Excess

ECICS
Excess