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 additional named driver(s)	{{ new.Quote.Driver }}
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

{{ (new.Quote.IsMainDriver === 'N' && new.Quote.OwnerType == Motor_Individual) ? 'Policyholder Name' : '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

Required Field Please enter a valid mobile number. Kindly avoid entering random or incorrect numbers. Invalid Mobile No.

Customer Email Address

Required Field 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}}

Named Driver {{$index +1}}

Main Driver Name Additional Name Driver {{ $index}} Additional Name Driver {{$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 Policyholder

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

Application 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 Name

Named Driver {{$index}}

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}}

Demerit Point:

{{ Motor.ddDemeritPointDesc }}

Relationship:

{{ppl.relationshipDesc}}

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.

Marketing Consent

By selecting yes to below, I/We consent to receive marketing communication from Etiqa on Etiqa's insurance products via the following channel.

Yes

I/ We can choose to withdraw my consent by submitting the Marketing Withdrawal From at www.etiqa.com.sg or email to customer.service@etiqa.com.sg. For more details, please refer to Etiqa's Data Protection Statement on Etiqa’s website.

Declaration

Unable to proceed Please check the box to agree to the Terms and Conditions before continuing.

Applicant's Consent and Declaration

All information provided by me in connection with this application are true, accurate and complete.
I agree that this application and declaration shall be the basis of the contract between Etiqa and myself.
If I do not fully and faithfully give the facts as I know them or ought to know them, I may receive nothing from the policy.
I agree to the policy terms, exclusions and conditions as expressed in the proposal form, policy wordings and endorsements.

Agent's Consent and Declaration

I have been duly authorised by the Applicant to act on his/ her/ their behalf for the purpose of applying for this insurance.
I confirm that I have read, informed and explained to the Applicant on the Policy Wordings, Application Summary, and Data Protection Statement. The Applicant understood and has agreed to it.
I also confirm that the Applicant has read and acknowledged the "Applicant's Consent and Declaration" section. I confirm I have duly obtained and retained the copy of the Applicant's acknowledgement of the "Applicant's Consent and Declaration" section. I will provide any necessary documentation as and when required by Etiqa or as mandated by applicable laws and regulations.
I confirm that all information provided in this Application and supporting document (where applicable) is accurate, true and complete to the best of my knowledge.
I declare that there is no conflict of interest in the arrangement of this insurance policy.
I agree to the policy terms, exclusions and conditions as expressed in the proposal form, policy wordings and endorsements.

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}}

Named Driver {{$index +1}}

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

Source of NCD (If different from insured)

Application Summary

{{wording.myPlanSelection}}

Company's Details

Main Insured's Details

Main Driver Name

Named Driver {{$index}}

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}}

Named Driver {{$index +1}}

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

Source of NCD (If different from insured)

Application Summary

{{wording.myPlanSelection}}

Company's Details

Main Insured's Details

Main Driver Name

Named Driver {{$index}}

Additional Named Driver {{$index + 1}}

Download Quotation Slip

Referred Quote

Existing Member

New Member