EmailMe Form - Renewal Form

Insured Name *
New I.C No *
H/P No *
Occupation
Home Address
Road Tax Delivery Address *
Car Registration No/Car Plate *
Car Model *
Keupayaan Enjin / CC *
Year Of Make *
Transmission *
Auto
Manual
No Engine *
No Chasis *
Finance By
Sum Insured RM *
Windscreen Cover RM
Current Insurer Company
Windscreen Cover *
Yes
No
NCD *
Total Premium RM *
Road Tax RM *
Total Bank In RM *
Bank Account :DF Happy Life Enterprise
Maybank 5144 8651 0117
Public Bank 3186 6145 34
Agent Code
Agent Name
Bank In Receipt
Geran Or Cover Note