1.
Period of Insurance
From:
07 Feb, 2012
08 Feb, 2012
09 Feb, 2012
10 Feb, 2012
11 Feb, 2012
12 Feb, 2012
13 Feb, 2012
14 Feb, 2012
15 Feb, 2012
16 Feb, 2012
17 Feb, 2012
18 Feb, 2012
19 Feb, 2012
20 Feb, 2012
21 Feb, 2012
22 Feb, 2012
23 Feb, 2012
24 Feb, 2012
25 Feb, 2012
26 Feb, 2012
27 Feb, 2012
28 Feb, 2012
29 Feb, 2012
01 Mar, 2012
02 Mar, 2012
03 Mar, 2012
04 Mar, 2012
05 Mar, 2012
06 Mar, 2012
07 Mar, 2012
08 Mar, 2012
09 Mar, 2012
10 Mar, 2012
11 Mar, 2012
12 Mar, 2012
13 Mar, 2012
14 Mar, 2012
15 Mar, 2012
16 Mar, 2012
17 Mar, 2012
18 Mar, 2012
19 Mar, 2012
20 Mar, 2012
21 Mar, 2012
22 Mar, 2012
23 Mar, 2012
24 Mar, 2012
25 Mar, 2012
26 Mar, 2012
27 Mar, 2012
28 Mar, 2012
29 Mar, 2012
30 Mar, 2012
31 Mar, 2012
01 Apr, 2012
02 Apr, 2012
03 Apr, 2012
04 Apr, 2012
05 Apr, 2012
06 Apr, 2012
07 Apr, 2012
08 Apr, 2012
09 Apr, 2012
10 Apr, 2012
11 Apr, 2012
12 Apr, 2012
13 Apr, 2012
14 Apr, 2012
15 Apr, 2012
16 Apr, 2012
17 Apr, 2012
18 Apr, 2012
19 Apr, 2012
20 Apr, 2012
21 Apr, 2012
22 Apr, 2012
23 Apr, 2012
24 Apr, 2012
25 Apr, 2012
26 Apr, 2012
27 Apr, 2012
28 Apr, 2012
29 Apr, 2012
30 Apr, 2012
01 May, 2012
02 May, 2012
03 May, 2012
04 May, 2012
05 May, 2012
06 May, 2012
07 May, 2012
08 May, 2012
09 May, 2012
10 May, 2012
11 May, 2012
12 May, 2012
13 May, 2012
14 May, 2012
15 May, 2012
16 May, 2012
17 May, 2012
18 May, 2012
19 May, 2012
20 May, 2012
21 May, 2012
22 May, 2012
23 May, 2012
24 May, 2012
25 May, 2012
26 May, 2012
27 May, 2012
28 May, 2012
29 May, 2012
30 May, 2012
31 May, 2012
01 Jun, 2012
02 Jun, 2012
03 Jun, 2012
04 Jun, 2012
05 Jun, 2012
06 Jun, 2012
07 Jun, 2012
08 Jun, 2012
09 Jun, 2012
10 Jun, 2012
11 Jun, 2012
12 Jun, 2012
13 Jun, 2012
14 Jun, 2012
15 Jun, 2012
16 Jun, 2012
17 Jun, 2012
18 Jun, 2012
19 Jun, 2012
20 Jun, 2012
21 Jun, 2012
22 Jun, 2012
23 Jun, 2012
24 Jun, 2012
25 Jun, 2012
26 Jun, 2012
27 Jun, 2012
28 Jun, 2012
29 Jun, 2012
30 Jun, 2012
01 Jul, 2012
02 Jul, 2012
03 Jul, 2012
04 Jul, 2012
05 Jul, 2012
06 Jul, 2012
07 Jul, 2012
08 Jul, 2012
09 Jul, 2012
10 Jul, 2012
11 Jul, 2012
12 Jul, 2012
13 Jul, 2012
14 Jul, 2012
15 Jul, 2012
16 Jul, 2012
17 Jul, 2012
18 Jul, 2012
19 Jul, 2012
20 Jul, 2012
21 Jul, 2012
22 Jul, 2012
23 Jul, 2012
24 Jul, 2012
25 Jul, 2012
26 Jul, 2012
27 Jul, 2012
28 Jul, 2012
29 Jul, 2012
30 Jul, 2012
31 Jul, 2012
01 Aug, 2012
02 Aug, 2012
03 Aug, 2012
04 Aug, 2012
for
1
year
2.
Date of Birth
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
dd
1
2
3
4
5
6
7
8
9
10
11
12
mm
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
yyyy
3.
Occupation / Position
4.
Full Description of Business Activity / Company Name ( Address & Contact Phone No.)
5.
Coverage:
Third Party Only
Comprehensive
Estimated Market Value ( Including accessories )
HK$
( For comprehensive coverage only )
6.
Vehicle
- Others -
1. Private Car
2. Goods Vehicel
If others, please provide
7.
Registration No.
8.
Brand
Model of Car
9.
Type of Body
10.
Cubic Capacity / Tons
11.
Seating Capacity
(Excluding Driver)
12.
Year of Manufacturing
13.
Chasis No.
14.
Driving Experience
(years)
15.
No Claim Bonus (NCB)
0
%
20%
30%
40%
50%
60%
16.
Hire Purchase Finance Company
17.
Name of Previous Insurer
18.
Policy No.
19.
Expiry Date
20.
Named Drivers
( maximum of 2 including the insured. Otherwise, additional premium is charged. )
Full Name of Driver
HK Driving
Licence No.
Age
Occupation
Driving Experience
1.
2.
more
21.
Questions:
a)
Has the vehicle been installed any additional Hi-Fi or equipment other than
manufacturer's standard specification?
Yes
No
If Yes, please provide full details:
b)
Has the vehicle been modified from standard specification?
Yes
No
If Yes, please provide full details:
c)
Will the vehicle be used
i)
for the carriage of passengers or goods for hired & reward?
Yes
No
ii)
for the carriage of dangerous goods?
Yes
No
If Yes, please provide full details:
d)
Has the vehicle been installed any anti-theft alarm?
Yes
No
If Yes, please provide full details:
22.
Previous Insurance: Have you or any of the regular drivers
a)
Been convicted of any motoring offence (other than parking offence) during the last 5
years or of any prosecutions pending?
Yes
No
If Yes, please provide full details:
b)
been disqualified from driving?
Yes
No
If Yes, please provide full details:
c)
had defective vision or hearing (not corrected by spectacles or hearing aid) or
suffered at any time from diabetes, fits, heart complaint or any other disease
or infirmity which may impair your ability to drive?
Yes
No
if Yes, please provide full details:
d)
ever been declined insurance or had your motor insurance been canceled or
renewal been refused by any insurer?
Yes
No
If Yes, please provide full details:
e)
ever made any motor claim under any motor insurance policy during the last 3
years?
Yes
No
If Yes, please provide full details:
Year
Insurance Company
Policy No.
Claims Amount
More...
Insured Information
23.
First Name
/
Given Name
24.
Last Name
/
Surname
/
Family Name
25.
Sex :
M
F
26.
Marital Status
Single
Married
Divorce
Widowed
27.
Mailing Address
Room
Floor
Block
Building
Street
District
Area
Hong Kong
Kowloon
New Territories
28.
HKID No.
29.
Day Time Contact No.
30.
Night Time Contact No.
31.
Fax No.
32.
E-mail Address