I will like to sign up as a new member on Etiqa’s online platform

Details of the applicant

Plan Details
Start Date	{{new.Quote.sDate}}
End Date	{{new.Quote.eDate}}
NCD Entitlement	{{Motor.NCD_ENTITLEMENTDesc}}
No. of named drivers	{{new.Quote.Driver}}
Cost Breakdown
{{ new.Quote.descCover }}	TBC	${{ new.Quote.Amount \| number:2 }}
{{ addon.AddOn_Description }}	TBC	${{ addon.premium \| number:2 }}	Added
Authority Discount	TBC	{{ new.Quote.authorityDiscountRate }}%
GST ({{ (UI.gstRate * 100) \| number:2 }}%)	TBC	${{ new.Quote.gst \| number:2 }}
Final Premium	TBC	${{ new.Quote.totalPrem \| number:2 }}

Quick Access :

Download policy wording

* Compulsory

Full Name of applicant

Invalid Name

Duplicate Name or Nric

Company Name

Invalid Company Name

Eligibility

Eligibility and NRIC/FIN No. do not match

NRIC / FIN No.

Invalid NRIC/FIN No.

Duplicate Name or Nric

Company Registration No.

Invalid Company Registration No.

Date of Birth

Please choose Date of Birth

Mobile Phone

Invalid Mobile No.

Customer Email Address

Invalid email address

Confirm Email

Email addresses do not match

Mailing Address

Unit No.

Invalid Unit No.

Postal Code

Incomplete Postal Code

Block No.

Please enter Block/House No.

Street Name

Please enter Street Name

Building Name

About the vehicle

Vehicle No.

Please provide Vehicle No.

Engine No.

Please provide Engine No.

Chassis No.

Please provide Chassis No.

Vehicle No. from previous insurer

Please provide NCD vehicle No.

Old Etiqa policy No. (Optional)

Please provide Old Etiqa Policy Number

Hire Purchase

Yes

Additional Information (Full quotation) *

You are required to fill in all the names driver(s) as well as claims experience for all driver(s) in order for the underwriters to give a complete outcome.

Additional Driver(s)

Main Driver

Named Driver {{$index +1}}

Additional Name Driver {{$index + 1}}

Please fill in name

Duplicate Name and Nric

Eligibility

Eligibility and NRIC/FIN No. do not match

NRIC / FIN No.

Invalid NRIC/FIN No.

Duplicate Name and Nric

Date of Birth

Please choose Date of Birth*

Driving Experience

Please select Year(s) of Driving Experience

Gender

Please select Gender

Marital Status

Please select Marital Status

Occupation

Please select Occupation

Relationship to the main driver

Please select Relationship

Claims Experience ({{ $index +1 }})

Date of Accident

Please fill in Date of Accident

Claim Amount

Invalid Claim Amount

Details

Please fill in claim details

Source of NCD (If different from insured)

Please fill in Source of NCD

Summary

Cover Package:

{{new.Quote.descCover}}

Start Date:

{{new.Quote.sDate}}

End Date:

{{new.Quote.eDate}}

NCD Entitlement:

{{Motor.NCD_ENTITLEMENTDesc}}

My Workshop:

{{Motor.MyWorkShop}}

Excess:

${{new.Quote.Excess}}

Premium Payable:

${{new.Quote.totalPrem | number:2}}

TBC

Promotional Discount:

{{new.Quote.discount_rate | number:2}}%

Company's Details

Main Insured's Details

Company Name: Name:

{{new.Proposer.ddNameID}}

Eligibility:

{{Proposer.ddEligibleID}}

Company Registration No.: NRIC/FIN No.:

{{new.Proposer.ddNRICID}}

Date of Birth:

{{Proposer.Dob}}

Gender:

{{genderDesc}}

Marital Status :

{{ddIsMarriedDesc}}

Occupation Nature:

{{ddoccupationNatureDesc}}

Year(s) of Driving Experience :

{{Motor.ddDrivingExperienceDesc}}

Demerit Point :

{{Motor.ddDemeritPointDesc}}

Hire Purchase:

{{new.Quote.Finance}}

Main Driver

Additional Named Driver {{$index +1}}

Name:

{{ppl.name}}

Date of Birth:

{{ppl.dob}}

Eligibility:

{{ppl.eligible}}

NRIC/FIN No.:

{{ppl.NRIC}}

Year(s) of Driving Experience:

{{ppl.drivingExperienceDesc}}

Communications

I wish to receive information, including marketing materials from Etiqa Insurance, from the following communication channels. By clicking yes, I accept and agree with Terms and Conditions for the Declarations and Undertaking.

Yes

If yes, please select mode of communication channel:

High Performance High Value Car

Online Life Insurance

High Performance High Value Car

Details of the applicant

Mailing Address

About the vehicle

Additional Information (Full quotation) *

Additional Driver(s)

Main Driver

Named Driver {{$index +1}}

Claims Experience ({{ $index +1 }})

Source of NCD (If different from insured)

Summary

{{wording.myPlanSelection}}

Company's Details

Main Insured's Details

Main Driver

Additional Named Driver {{$index +1}}

Download Quotation Slip

Referred Quote

High Performance High Value Car

Online Life Insurance

High Performance High Value Car

Details of the applicant

Mailing Address

About the vehicle

Additional Information (Full quotation) *

Additional Driver(s)

Main Driver

Named Driver {{$index +1}}

Claims Experience ({{ $index +1 }})

Source of NCD (If different from insured)

Summary

{{wording.myPlanSelection}}

Company's Details

Main Insured's Details

Main Driver

Additional Named Driver {{$index +1}}

Download Quotation Slip

Referred Quote

Existing Member

New Member