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Motor Insurance Proposal Form

Today is 02-12-2015
Name and Surname:
Phone: *
Email: *
Detail of Vehicle
Make/Brand: * Ex: Toyota/Vios
Year Manufactured:
Plate No: *
Seating Capacity: *
Cubic Capacity: *
Engine No: *
Chassis No: *

Usage Type: *

Private Public Motorcycle Car
Bus Express Bus Truck Chemical/Petroleum
Cover Option: *
Compulsory Option 3 Option 4 Own Damage Cover
Period of Insure: *
From:   To:  
* *