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AutoPlus Proposal Form P1.

ai

2/18/08

2:16:34 PM

AutoPlus PROPOSAL FORM

THIS INSURANCE WILL NOT BE VALID IF YOU DO NOT:


Complete all the fields in the Proposal Form Declare truthfully Sign on the Proposal Form

OTHER IMPORTANT NOTES:


If the vehicle you are purchasing is registered under company's name, please endorse the company's stamp on the Proposal Form. An Elderly, Young and/or Inexperienced Driver Excess (EYIDR) of S$2,000 in addition to the Policy Excess applies to You or an Authorised Driver (Named and Un-named) who is above age 65, below age 23 (if applicable) and/or has less than 1 year's driving experience. This policy is subject to drivers age condition. The policy will indemnify the insured or any authorised driver only if he/she meets the age condition. Please refer to policy terms and conditions. For Named-Driver(s)-Only Policies, All Age Condition will not apply. Kindly attach payment with Proposal Form.

Underwritten by

American Home Assurance Company, Singapore

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

AutoPlus Proposal Form P2-P4.ai

2/13/08

4:31:34 PM

PROPOSAL FORM FOR AutoPlus


(For private car only)

Policy Reference No.

OTHER POLICY OPTIONS (SUBJECT TO CHANGES IN PREMIUM)


To select benefit option, please tick () accordingly: Increase / Reduce excess (below excess subject to prevailing GST) Increase excess to: S$800 S$1,800 Or, reduce excess to: S$400 S$1,000 S$2,000 S$200 S$1,200 S$2,500 S$0 S$1,400 S$3,000 S$1,600

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

ABOUT THE PROPOSER


Is this an Insured-Not-Driving policy?
Name
Dr./Mr./Mrs./Ms./Prof.*

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)

Gender Marital Status Driving Exp

Male Single

Female Married (Yrs) Others

Full Annual Payment

(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)

Subject to DBS Card Agreement Terms & Conditions

*** 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)

IMPORTANT NOTICE TO PROPOSER


This is an authorised workshop scheme which requires all accident repairs to be done at any Workshops listed in the Certificate of Insurance. An Elderly, Young and/or Inexperienced Driver Excess (EYIDR) of S$2,000 in addition to the Policy Excess applies to You or an Authorised Driver (Named and Un-named) who is above age 65, below age 23 (if applicable) and/or has less than 1 year's driving experience. This policy is subject to drivers age condition. The policy will indemnify the insured or any authorised driver only if he/she meets the age condition. Please refer to policy terms and conditions. If this proposal is accepted or when the cover commences, it is a fundamental and absolute Special Condition of this contract of insurance that for individually-owned policies, the premium due must be paid to the insurer/broker/agent before the inception of the cover. This document is not a contract of insurance. The specific terms, conditions and exclusions applicable to the insurance are set out in the Policy. No insurance is in force until the Company has accepted this Proposal.

Record of revoked/endorsed driving license NCD (%) COM** (5%) Yes (Please attach COM from Traffic Police)

Year: First time owner Others (please specify)

Reason: 2nd or 3rd vehicle Have been driving company's/relatives' vehicles

ACKNOWLEDGED AND DECLARED BY


I/We declare 1. That in respect of any of the risks incurred, no circumstances exists which renders such risks abnormal. 2. That the above particulars to be true and correct and I/we agree that my/our warranties, declarations and disclosures herein shall form the basis of the contract between the Company and myself/ourselves. 3. And agree on behalf of myself/ourselves and any person(s), firm or corporation, that any information collected or held by the Company (whether contained in this Proposal Form or otherwise obtained) may be used and disclosed by the Company, its associated individuals/companies or any independent third parties (within or outside Singapore) for any matter relating to this Proposal Form, any Policy issued and to provide advice or information concerning products and services which the Company believes may be of interest to me/us, and to communicate with me/us for any purpose. 4. That the No Claim Discount (NCD) is as stated and I am/we are aware that I/we have to effect a cancellation of my cover with my existing/ex-insurer in order for the declared NCD to be applied from the inception of this risk proposed. If I/we have opted for the 0% Interest Installments, I/we agree to be bound by DBS Terms and Conditions Governing Installment Payment Plan posted at www.dbs.com.sg

If NCD is nil or 10% with no claims experience, please provide the reason:

Is NCD to be transferred from existing/previous insurer? Previous Insurer: Policy No:

Yes (pls provide details below) Registration No: Expiry/Cancellation Date:

** 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

ABOUT THE VEHICLE


Period of Insurance From Make & Model Engine No Chassis No Hire Purchase Co Seating Capacity

Signature: Body Type Saloon SUV Registration No Insurance with COE/PARF?*** Off-Peak Car? Yes Yes No No Coupe Others
(please specify)

Company Stamp (if applicable): Date:

D D M M Y Y

to midnight of

D D M M Y Y
Year of Registration Engine Capacity

MPV

Name of Proposer:

PREMIUM DETAILS (FOR OFFICIAL USE)


Basic Premium: Less: % No Claim Discount S$ S$ S$ S$ S$ cc S$ S$ Excess: S$
Insurer's Copy

Less: 5% Certificate of Merit Discount Less: Off-Peak Car Discount Add: Fixtures and Accessories

Total Premium Payable:

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.

DRIVER AGE CONDITION


Important Note: This policy is subject to drivers age condition. The policy will indemnify the insured or any authorised driver only if he/she meets the age condition. Please refer to policy terms and conditions.
Choose from one of the following options: All age condition 30 years old & above age condition
Reference No: PL-PF202-02/08 American Home Assurance Company Singapore

Add: Loss of Use Benefit Add: Others Underwritten by

FOR OFFICIAL USE


AHAC - Underwriter AHAC - CSG

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

Signature & Date

Signature & Date