AXA INSURANCE

SINGAPORE

PTE LTD

143 Ceol Street #0101 GB Building ':ingapore 069542 Tel: 1800 B80 4741 Fax: 68804783 Internet: http://WWN.axa.com.sg Co. Reg No. I 969004000

11
SmartDrive Private

D. NAMED DRIVERS'PARTICULARS

Name (asin NRIC pleaseunderline surname) NRIClPassportNo. Date of birth

Ouotation Reference Number

Gender MaritaI Status Nationality

Male / Female Single/ Married / Others

Male I Female SingleI M<lrriedI Others

IMPORTANT

NOTES

I. Section 25(5) of the Insurance Act Cap 142 or any subsequentamendment thereof requiresyou to tell us (AXAInsurance

YearDriving Licence Obtained Relationship to Proposer Occupation Claim, if any No Claim Discount If any
% %

Singapore PteLtd) everything you know, or could reasonablybe expectedto know, that is relevantto our decisionto insure
you, otherwise the Policyissuedmaybe void. 2. Our liability in respectof this proposal does not commenceuntil acceptancehasbeen communicated by usto you. 3. Yourpolicy carriesa PaymentBefore CoverWarranty Clause,which requiresthe premium to be paid in full on or before the

inception date of the cover.Thisis applicablefor individual insured.For non-individualinsured,your policy carries Premium a Warranty Clause,which requiresthe premiumto be paid in full within 60 daysfrom the commencementof the cover.Failing to comply with the above, there would be no liability under the Policy.
4. You must answer all the questions in this Application Form, Any questionsnot answered will be taken asansweredin the

E. OTHER INFORMATIONS

(Please Circle Your Answer)

negative
5, If the space provided is insufficient, pleasewrite the details on a separatesheet of paper and attach it to this Application

Do you or any of the drivers stated in this form have or ever had: (a) Any physical or mental infirmity or defective vision or hearing? (b) Any traffic conviction (excluding parking fines) in the last 3 years? (c) Any accident in the last 3 years? If yes, please give details and amount:
in Nric, please underline surname, _

Yes/No Yes/No _ _ Yes/No Yes/No _

Form.

A. PROPOSER
Full name of Proposer IAs shown
D MrD Ms D MrsO Mdm 0 Dr

(d) Been entitled to any "No Claim Discount"? If yes, please indicate: NCD entitlement Previous Insurer Vehicle No

Passport / Nric No Nationality TeiND. Address _

Marital Status

Date of Birth

2
Gender 0 Male 0 Female

Has any insurance company or underwriter at any time in respect of motor insurance (new or renewal) in your name or in the name of any other person who, to your knowledge, drives the car:

(0)

(H)

(Mobile) _

(a) Declined any proposal? (b) Cancelled any policy of insurance? (c) Imposed an excess or other special terms?

Yes/No Yes/No Yes/No Yes/No _

Driving Experience

Years

occupation

(d) Refused to renew any policy of insurance? If your answers to any of the above question is "Yes", please give detats:

B. VEHICLE DETAILS
Make and Model --Body Type ';Rline Capacity _ Chassis No Registration No . Year-oLMake __ _

--=----~==_
_ _ _

F. PAYMENT METHOD

Engine No Seating Capacity (excluding driver) Finance CoJBanklEmployers Any Modification? OYes Loan ----OND

Credit Card Type of Card 0 VISA Cardholders Name:

0 MasterCard

0 Amex

0 Diners
_

o o

Cash - Please do not send cash via mail CheqUE - Crossed and made payable to AXA Insurance Singapore PIe Ud Bank _

Credit Card No.: Expiry date: To _

I I I U I I LLU I I I I I I

C. COVER DETAILS
Period of Insurance Coverage From 0 Comprehensive 0 Yes 0 No

W~
Date: _

Card Verification Value Code (CW*): ~ Cardholder's signature:

Creque ~Io.
Premium Arrounl
jlJ51

_
_

:i Third Party Fire & Theft 0 Third Party Only

Off-Peak Car: 0 Yes 0 No

Exclude COE:

* CW2- Applicable to Visaand MasterCardonly. The CW is the last 3-digit no. printed reverseitalics; n the backof your card. o

above che signature panel in

N'CO Protector: 0 Yes 0 No (Applicablefor 50% NCOwith no ea ims in previousyear only)

G. SMARTDRIVE UNDERTAKING
Enjoy 15% discount" on AXA Premium Workshops 0 Yes 0 No (If yes, please see below)

To use AXA Premium Workshops in the event of Motor claims

You agree Workshops that. in consideration located of your agreement in Singapore to use exclusively anyone ofAXA Premium Exclusive

strategically

for all your accident to your Policy:

repairs, the following

SmartDrive Private
APPLICATION FORM

Benefits will be accorded Exclusive 1. 2. Benefits

to you and endorsed

For Agreement 15%'

To Use AXA Premium Excess for Insured

Workshops and Named Drivers as follows;

Premium Reduction

discount

of Basic Own

Damage

50% NCD - Nil Excess 0% to 40% NCO - Excess halved 3. Nine (91 Months Warranty Young for Repairs & Inexperienced Driver Excess to 5$2,500 Thailand in Singapore to the main driver onlYI driving following this in West Malaysia accidenUrobbery benefit is applicable & Peninsular 4. Reduced 6. 7. Undeclared

5. RepCltriation
Personal

cost whilst effects

Loss of Personal Accident (If the Insured

Benefits

of 5$30,000

is a company,

This Undertaking to use AXA Premium Workshops will remain in force for the current period of Insurance .This undertaking will continue to remain inforce on renewal of the policy unlessotherwise instructed by you in writing to AXA.

You confirm that you understand that in the event that you do not have your accident repairs done at an AXA Premium Workshop, AXA shall not be liable to indemnify you for the costs of any repairs to your car undertaken by other workshop or repairer or to provide you with any of the benefits mentioned above.

ALl Premium Workshops stud] mean such repairers or workshops are appointed by AXA from time to time, and are su'1ect 10chill~ger.

H. DECLARATION & SIGNATURE

I. ___ 2. I declare and agree to insure my motor vehicle with IV<A Insurance Singapore Pte Ltd and I agree to accept the_Col1Jp.9-U)!:'s Policy SUbject to the terms, conditions and exceptions of the Policy. I declare that the abovementioned IvlotorVehicle is and wiWl5e Kept in goodcondition. -I undertake that all answers given in this proposal are true and correct and that this Proposal and Declaration shall form part of the contract between the Company and myself.

3. I agree to give my consent for the Company to verify any given inFormation with the relevant authority. 4. I acknowledge that should there be a change in any information provided, the premium quoted may be revised. I Further acknowledge that the No Claim Discount is subject to confirmation by my current insurer and any difference in the No Claim Discount may affect the basic premium quoted.

Signature
, AI'W 5cherrediscountis revi~ed 15% w.e.f. 1st March 2008 to

Date

m/I\PPf020S