Free servicing (worth $123) with every new direct motor insurance policy with Dickson!

INSURED DETAILS

Full name* —Please choose an option—MrMrsMdmMsProfDr Mobile No.* E-mail address* NRIC / FIN no.* Date of birth* Driving licence pass date* Gender* —Please choose an option—MaleFemale Marital status* —Please choose an option—SingleMarriedDivorced Occupation*

ADDITIONAL NAMED DRIVER (OPTIONAL)

Full Name —Please choose an option—MrMrsMdmMsProfDr NRIC / FIN no. Date of birth Driving licence pass date Gender —Please choose an option—MaleFemale Marital status —Please choose an option—SingleMarriedDivorced Occupation Relationship with the Insured

VEHICLE DETAILS AND COVERAGE REQUIRED

Upload your vehicle log card or fill in the form below Coverage Required* —Please choose an option—ComprehensiveThird Party Fire and Theft (TPF)Third Party Only (TPO) Vehicle Registration Number Vehicle Make & Model Vehicle Registration Date Vehicle year of Manufacture —Please choose an option—202120202019201820172016201520142013201220112010200920082007200620052004200320022001 Vehicle engine capacity

NCD AND CLAIM(S)

Upload your policy renewal notice or fill in the form below No claims discount upon renewal (NCD)* —Please choose an option—0%10%20%30%40%50% Any accident resulting in a claim in the last 3 years* —Please choose an option—YesNo If YES, please provide date of accident and claim amount if known

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Additional notes

I have read the consent provisions relating to the collection, use and disclosure of my personal data for the purposes of receiving survey forms, receiving information on events, programs, promotions, receiving marketing messages including information on new products and services, via text, telephone call, email and post, from the Dickson group of companies. My consent is voluntarily given and I am aware that I may withdraw my consent any time by emailing to [email protected]. I am also aware my right to access my personal data. I have checked and do confirm the same to be true, complete and accurate.