www.chartisinsurance.com.

sg

CHARTISG-

Producer Name: Producer Code/SubCode

Contact No.: Policy Reference No.

ABOUTTHEPROPOSER
Is this an "Insured-Not-Driving" Name policy? DYes ONo
and underline Surname.)

Type of Coverage

-,

Comprehensive

Dr.

o
No*

Mr. 0 Ms. (Please

enter Full Name as per your NRICjROCjPassport

NRIC/PassportjROC

I
No) (Level-Unit No) Date of Birth Nationality

Residential Address

(Block/House (Street Name)

IJIDIMjMlv
o Singaporean
o Others

I"IV
o

IV

Permanent Resident

(Building Name) (Singapore)

=1

(Please specify no. of years in Singapore) ___

I
!

IT]
(Office) (Fax) I

Gender Marital Status Driving Exp

o Male

o Female

Contact Details

(Mobile) (Residential) (Email)

Others o Single o Married o (please specify) __

(Yrs)

(Mths)

Name of Employer
I

Occupation/ Nature of Business

I
Otherwise, declarations will be taken as 'NO'.

Job Nature

Mostly Indoor

o Mostly
1<

Outdoor
where applicable.

Delete

DECLARATIONS
Please tick (v') below where applicable.

o At fault

claims experience in past 3 years (please provide details below)

Date of accident (dd/mrn/yy)

,
!

Description of accident

Amount of claim (s)

Type of claim
(Own Damage/Third Party\Theft/Bodily Injury)

I
NCD%

I
insurer?

If NCD is nil or 10% with no claims experience, please provide the reason:

Is NCD to be transferred from existing/previous

o o o

First time owner Others (please specify)

o znd or 3rd vehicle

o Have been driving

company's/relatives'

vehicles

Yes (pis provide details below and arrange to effect a cancellation of your cover with your existing insurer in order for the declared NCD to be applied from the inception of this risk proposed.) Registration No: Expiry/Cancellation Date:

Previous Insurer: Policy No:

REVOKED AND ENDORSED LICENCE

o Record of revoked/endorsed
Duration of revoked licence

driving licence

Date revoked _

Reason: Alcohol limit NCD before the licence was revoked mg/breath or _ mg/blood

Any accident when the licence was revoked?

0 Yes 0 No

Driving experience before the licence was revoked

ABOUT THE VEHICLE

Period of Insurance Make & Model Engine No Chassis No Hire Purchase Co
***When insuring without COE/PARF, please inform the financier(s) if vehicle

From

I~ I I ~ IVII I
'y

to midnight of

I- I
Engine Capacity

IV

IM I v I '

Body Type

o Saloon
OSUV

Year of Registration Registration No Insurance with COE/PARF?*** Off-Peak Car?

o Coupe o Others (please specify)

ONo ONo

OMPV

DYes DYes

Seating Capacity

financing is involved. In this instance, in the event of total 1055, the Insured will recover the residual value of the COE/PARF from LTA.

DRIVER AGE CONDITION

Important Note: This policy is subject to driver's where age condition. The policy will indemnify the insured will apply: or any authorised driver only if he/she meets the age condition. Please tick (,f) below Choose from one of the following options: applicable. Otherwise, "All Age Condition"

o All age condition

Reference No: Pl-PF201-12/0g

o 30 years old & above age condition

o 35 years old & above age condition

o 40 years old & above age condition

1111111111111111111111111111111111111111111111111I
'U0100110'

ABOUT THE NAMED DRIVER(S)

For models that require named drivers.

PLEASE TICK

(v)

IF THIS IS A NAMED-DRIVER(S)-ONLY

POLICY.
under the policy.

For Named-Driver(s)-Only Driver's Name (1) Occupation Driver's Name (2) Occupation

policies, all UN-NAMED drivers will NOT be indemnified

Date of Birth

I IJ I .
I

o Mostly o Mostly
revoked licence history in the past 3 years if applicable. Date of Accident! Licence Revoked

Indoor

o Mostly o Mostly

I I
V

Diving Exp Relationship to Proposer Diving Exp Relationship to Proposer

(Yrs)

(Mths)

Outdoor

I Date of Birth I
Indoor

11\ I " I " I

Outdoor' declaration

(Yrs)

(Mths)

Please provide claims and/or

Otherwise,

will be taken as 'NONE'. Applicablefor ClaimsOnly

Driver
(1)( (2)

I
y

Duration Revoked

Reason for Revoked Licence/ Nature of Accident

Amt($) (If claim)

Type of claim (Own Damage/ThirdParty/ Theft/Bodily Injury)

.- I [) I 'i I " , i [ i" ,: I i

!

~ !
!

OTHER POLICY BENEFIT OPTIONS (ADDITIONAL

To select benefit option, please tick (V) accordingly:

PREMIUM APPLIES)

o o o

Loyalty Home Cover @ $101.65 (With 7% GST) (insuredproperty will be insured'sresidentialaddressas in this proposal) Fixtures and Accessories (pleaseprovidedetails and attach invoice) Others [Please tick (y') and circle accordingly] Pleasemakechequepayableto: American Home Assurance Company _

PAYMENT MODE

o Cash o Credit

Cheque

Bank

Cheque No

Card (MasterCard / Visa / American Express)

I/We hereby authorise American Home Assurance Company, Singapore Branch (AHA) to charge the stated annual premium to the following credit card. Where a third party credit card is used I/we declare that the card holder has authorised and consented to its use.

Full Annual Payment

o Monthly o 6 Monthly
12

0% 0%

Interest Installments with DBS' /POSB/ UOB' credit cardt Interest Installments with DBS' /POSB/ UOB' credit card"

Name as on card: Card No:

ITIIJ-ITIIJ-ITIIJ-ITIIJ
Express Cardholder, please fill up your card number from the second box)
$$100

Card Expiry Date:

(If you are an American

2

, Not applicablefor DBSCorporateCards/DBSAMEXCredit Cards/BlackCards

t

For UOB 0% installment plan (IP), an administrative fee of Subject to the bank's Card Agreement Terms & Conditions

is payable in the event of premature

cancellation

or fermi nation of the IP

and/orcredit card account.

Amount: S$

r-r-r-r-.

IMPORTANT

NOTICE TO PROPOSER

This is an authorised workshop scheme which requires all repairs to be done at any AHA Authorised Workshop listed in the Certificate of Insurance. For vehicles less than 3 years old, You have the option to have accident repairs done at the Sole Agent's Workshop. An Elderly, Young and/or Inexperienced Driver Excess(EYIDR) of 5$3,000 in addition to the Policy Excessapplies to You or an Authorised Driver (Named and Un-named) who is above the age of 65, below the age of 23 (if applicable) and/or has less than 2 years' driving experience. This policy is subject to driver's age condition. The policy will indemnify the insured or any authorised driver only if he/she meets the age condition. Pleaserefer to policy terms and conditions. If this proposal is accepted or when the cover commences, it is a fundamental and absolute Special Condition of this contract of insurance that for individually-owned policies, the premium due must be paid to the insurer/broker/agent before the inception of the cover.
This document is not a contract of insurance. The specific terms, conditions and exclusions applicable to the insurance are set out in the Policy. No insurance is in force until American Home Assurance Company,

SingaporeBranch,hereinafter referredto as'the Company',hasacceptedthis Proposal.

ACKNOWLEDGEMENT
1.

AND DECLARATION

2.

I/We declare That in respect of any of the risks incurred, no circumstances exists which renders such risks abnormal. That the above particulars to be true and correct and I/we agree that my/our warranties, declarations and disclosures herein shall form the basis of the contract between the Company and myself/ourselves. 3- And agree on behalf of myself/ourselves and any person(s), firm or corporation, that any information collected or held by the Company (whether contained in this Proposal Form or otherwise obtained) may be used and disclosed by the Company, its associated individuals/companies or any independent third parties (within or outside Singapore) for any matter relating to this Proposal
Form, any Policy issued and to provide advice or information concerning products and services which the Company believes may be of interest to me/us, and to communicate with me/us for any

purpose. t 4. That I/we understand that the Company will verify the NCD with my/our existing/ex-insurer on the declared NCD entitlement. Unless otherwise require to do so by the Company, I/we hereby undertake to pay any difference in the premium amount owing which may arise in the event of a discrepancy between the NCD provided by my/our existing/ex-insurer and the declared figure by me/us; failing which the Policy shall ceaseto be in force either upon the expiry of any notice which the Company may give for the purpose of cancelling the Policy or if no such notice is given, upon the expiry of such reduced period of coverage as the Proposer is ratably entitled to having regard to the portion that the premium paid bears to the premium properly payable. Signature: Name of Proposer: _ Company Stamp (if applicable): Date:

PREMIUM DETAILS (FOR OFFICIAL USE)

Basic Premium' Less:
%

S$ 1
No Claim Discount

S$I S$I S$ 1 S$ 1 S$ 1

Less: Off-Peak Car Discount Add: Loyalty Home Cover @ $101.65 (with 7% GST) Add: Fixtures and Accessories Add: Others

I I
I
I
I

GST: Total Premium Payable: Excess:

[ss [ss [ss

FOR OFFICIAL USE Producer
AHA - Underwriter

AHA- CSG

Underwritten

by

American Home Assurance Company, Singapore Branch Incorporated in the United States with liability limited.

Signature s Date

Signature & Date

Sigl1~ture&

Dat~