The Overseas Assurance Corporation Limited (Reg. No.

1920 00003W)
(a wholly-owned subsidiary of Great Eastern Holdings Limited)

1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: (65) 62482608 / 62482609 Fax: (65) 63273012 / 63273013 Website: www.Lifeisgreat.com.sg

MOTOR PROPOSAL FORM

IMPORTANT NOTE: Statement Pursuant to Section 25(5) of the insurance Act (Cap 142) (or any subsequent amendment thereof) you are to disclose in this proposal form, fully and faithfully all the facts which you know or ought to know in respect of the risk that is being proposed, otherwise the policy issued hereunder may be void.

PARTICULARS OF PROPOSER
AGENCY NAME / CODE REGISTRATION NO.

PARTICULARS OF VEHICLE
YEAR OF MANUFACTURE C.C. / TON

FULL NAME OF PROPOSER (*MR/MDM/MISS)

MAKE / MODEL

ENGINE NUMBER

ADDRESS (AS IN NRIC)

SEATING CAPACITY (including driver)

CHASIS NUMBER

TEL NOS. (OFF) (RES) (H/P) DRIVING EXPERIENCE (YRS)

*NRIC / PP NO.

DATE OF BIRTH

ESTIMATED MARKET VALUE (for commercial vehicle only)

HIRE PURCHASE CO / BANK / EMPLOYEES LOAN (if any)

NATIONALITY TYPE OF BODY: Please tick ( SALOON DEMRIT POINTS IN LAST 2 YRS ACCESSORIES: Please tick ( ) SPORTS RIMS OTHERS (SPECIFY: ) COUPE ) OTHERS (SPECIFY: )

OCCUPATION:

(*INDOOR / OUTDOOR)

AIR-CON

CD PLAYER

RADIO/CASSETTE PLAYER EMPLOYERS NAME

IS THE VEHICLE MODIFIED OR ALTERED FROM THE ORIGINAL VEHICLE SPECIFICATIONS? * YES / NO IF YES, PLASE GIVE COMPLETE DETAILS

ACCIDENTS /CLAIMS IN LAST 3 YEARS (YES/NO) YEAR OF ACCIDENT OWN DAMAGE CLAIM S$ 3RD PARTY CLAIM S$

PERIOD OF INSURANCE
FROM: ( am/pm) TO: (MID NIGHT)

PARTICULARS OF NAMED DRIVER

Please attached extra copy if there are more than one named driver
FULL NAME (*MR/MDM/MISS) Please tick ( )

TYPE OF COVER
COMPREHENSIVE COMPREHENSIVE DRIVE N SAVE 3RD PARTY ONLY

DATE OF BIRTH

*NRIC / PP NO.

OCCUPATION

3RD PARTY IRE & THEFT

DRIVING EXPERIENCE

DEMRIT POINTS IN LAST 2 YRS

OPTIONAL BENEFITS
AMT INSURED S$ BREAKAGE OF WINDSCREEN

ACCIDENTS /CLAIMS IN LAST 3 YEARS (YES/NO) YEAR OF ACCIDENT OWN DAMAGE CLAIM 3RDPARTY CLAIM

OTHERS, please specify

PARTICULARS OF CURRENT INSURANCE

NAME OF INSURANCE COMPANY

For Office Use Only

REGISTRATION NO.

POLICY NO.

EXPIRY/CANCELLATION DATE OF INSURANCE

NO CLAIM DISCOUNT (%)

Any insurance with OAC? Please specify

DECLARATION AND SIGNATURE *I/we hereby declare and agree to insure *my/our Motor *Vehicle/Cycle with THE OVERSEAS ASSURANCE CORPORATION LTD and *I/we agree to accept the Corporations Policy subject to the provisions and conditions of the Policy. *I/we hereby declare that the above mentioned Motor *Vehicle/Cycle is and will be kept in good condition. *I/we hereby warrant that all the answers given in this proposal are true and correct, that this Proposal and the Declaration shall form part of the contract between the Corporation and *myself/ourselves.

_________________________________________________

*Please delete where necessary

SIGNATURE OF PROPOSER & DATE

Motor_Proposal_Form_17092007