BORANG PERMOHONAN MEMPERBAHARUI INSURANS & CUKAI JALAN

Tarikh Permohonan (Date):
Jenis Permohonan (Transaction Type):	Permohonan Baru (New Registration) Memperbaharui (Renew) Memindahkan (Transfer)
Nama Pemohon (Name):
No. Kad Pengenalan (New IC / Old IC):
Alamat Tetap (Permanent Address):
Alamat Surat Menyurat (Posted Address):
No. Telefon (Contact No.):
Kelas Kenderaan (Class):	Kenderaan Persendirian (Private Car) Kenderaan Perdagangan (Business)
Jenis Perlindungan (Cover Type):	Komprehensif (Conprehensive) 3rd Parti Kebakaran & Kecurian (3rd Party Fired & Theft)
Tarikh Tamat Cukai Jalan (Expired Date):
No. Pendaftaran Kenderaan (Registration No):
No. Geran Kenderaan (Card No.):
No. Enjin (Engine No.):
No. Casis (Chassis No.):
Model & Pengeluar (Make & Model) Contoh: Proton - Proton Persona 1.6 (AT)
Tahun dibuat / didaftarkan (Year of Manufactured):
Kapasiti Enjin (Capacity):
Bank Pembiaya Kenderaan (Hide Purchase):
NCD % Current Value :
Perlindungan Tambahan (Additional Coverage):	Cermin Hadapan (Windscreen) Kemalangan Peribadi (Personal Accidental) Tidak Perlu (N/A)
Tahun Lesen Memandu Dikeluarkan (Year of License Issued):
Pekerjaan (Occupation):
Syarikat Insurans Dahulu & Cawangan (Previous Insurer & Branch):
No. Polisi Dahulu (Previous Policy No.):
Alamat Emel (Email Address):

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