o Record of revoked/endorsed driving licence Date revoked _

Duration of revoked licence _

Any accident when the licence was revoked? 0 Yes 0 No

Driving experience before the licence was revoked

Reason:

Alcohol limit mg/breath or mg/blood

NCD before the licence was revoked _

www.chartisinsurance.com.sg CHARTISG-

Producer Code/SubCode Policy Reference No.

Producer Name: Contact No.:

ABOUTTHEPROPOSERIs this an "Insured-Not-Driving" policy? DYes ONo I Type of Coverage -, Comprehensive

Name o Dr. o Mr. 0 Ms. (Please enter Full Name as per your NRICjROCjPassport and underline Surname.)

NRIC/PassportjROC No* IResidential (Block/House No) (Level-Unit No) Date of Birth IJIDIMjMlv I"IV IVAddress

(Street Name) Nationality o Singaporean o Permanent Resident

(Building Name) o Others (Please specify no. of years in Singapore) ___

(Singapore) =1 I ! IT]! Gender o Male o Female

Contact (Mobile) (Office) Marital Status o Single o Married o OthersDetails (please specify) __

(Residential) (Fax)Driving Exp 0 (Yrs) (Mths)

(Email) I

Name of EmployerI

Occupation/ I I Job Nature o Mostly Indoor o Mostly OutdoorNature of Business

1< Delete where applicable.

DECLARATIONSPlease tick (v') below where applicable. Otherwise, declarations will be taken as 'NO'.

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

Date of accident,

Type of claimDescription of accident Amount of claim (s)

(dd/mrn/yy)!

(Own Damage/Third Party\Theft/Bodily Injury)

INCD% IIf NCD is nil or 10% with no claims experience, please provide the reason: o First time owner o znd or 3rd vehicle o Have been driving company's/relatives' vehicles

o Others (please specify)

Is NCD to be transferred from existing/previous insurer? o Yes (pis provide details below and arrange to effect a cancellation of your cover with your existing insurerin order for the declared NCD to be applied from the inception of this risk proposed.)

Previous Insurer: Registration No:

Policy No: Expiry/Cancellation Date:

REVOKED AND ENDORSED LICENCE

ABOUT THE VEHICLEPeriod of Insurance From I~ I I ~ IVII 'y I V I to midnight of I - I .

IV IM I v I ' Body Type o Saloon o Coupe OMPV

Make & Model Year of OSUV o OthersRegistration (please specify)

Engine No Engine Registration NoCapacity

Chassis No Insurance with DYes ONoCOE/PARF?***

Hire Purchase Co Seating I Off-Peak Car? DYes ONoCapacity

***When insuring without COE/PARF, please inform the financier(s) if vehicle 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

o All age condition o 30 years old & above age condition o 35years old & above age condition o 40 years old & above age condition

Important Note: 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.Please tick (,f) below where applicable. Otherwise, "All Age Condition" will apply:

Choose from one of the following options:

Reference No: Pl-PF201-12/0g

1111111111111111111111111111111111111111111111111I'U0100110'

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

o Loyalty Home Cover @ $101.65 (With 7% GST) (insuredpropertywill be insured'sresidentialaddressasin this proposal)o Fixtures and Accessories (pleaseprovidedetailsandattach invoice) _

o Others

ABOUT THE NAMED DRIVER(S)For models that require named drivers.

PLEASE TICK (v) IF THIS IS A NAMED-DRIVER(S)-ONLY POLICY.For Named-Driver(s)-Only policies, all UN-NAMED drivers will NOT be indemnified under the policy.

Driver's Name (1) IDate of Birth I IJ I . I I V I V Diving Exp (Yrs) (Mths)I

Occupation o Mostly Indoor o Mostly Outdoor Relationship to Proposer

Driver's Name (2) I Date of Birth I I 11\ I " I " I Diving Exp (Yrs) (Mths)

Occupation o Mostly Indoor o Mostly Outdoor' Relationship to Proposer

Please provide claims and/or revoked licence history in the past 3 years if applicable. Otherwise, declaration will be taken as 'NONE'.

Date of Accident! IApplicablefor ClaimsOnly

Driver Duration Revoked Reason for Revoked Licence/ Amt($) Type of claim(1)( (2) Licence Revoked Nature of Accident (If claim) (Own Damage/ThirdParty/

Theft/Bodily Injury)

.- I [) I 'i I " v

, i [ i" ,: ~ ! y

I ! i !

OTHER POLICY BENEFIT OPTIONS (ADDITIONAL PREMIUM APPLIES)

PAYMENT MODE [Please tick (y') and circle accordingly]

(If you are an American Express Cardholder, please fill up your card number from the second box), Not applicablefor DBSCorporateCards/DBSAMEXCredit Cards/BlackCards I2 For UOB 0% installment plan (IP), an administrative fee of $$100 is payable in the event of premature cancellation or fermi nation of the IP and/orcredit card account. Amount: S$t Subject to the bank's Card Agreement Terms & Conditions

o Cash o Cheque Pleasemakechequepayableto: American Home Assurance Company I Bank I I Cheque No Io Credit 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 usedI/we declare that the card holder has authorised and consented to its use.

o Full Annual Payment o 12 Monthly 0% Interest Installments with DBS' /POSB/ UOB' credit cardt

o 6 Monthly 0% Interest Installments with DBS' /POSB/ UOB' credit card"

Name as on card:

Card No: ITIIJ-ITIIJ-ITIIJ-ITIIJ Card Expiry Date: r-r-r-r-.

IMPORTANT NOTICE TO PROPOSERThis 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 theoption to have accident repairs done at the SoleAgent'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 lessthan 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 mustbe 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 AND DECLARATION

Signature: _ Company Stamp (if applicable):

I/We declare1. That in respect of any of the risks incurred, no circumstances exists which renders such risks abnormal.2. 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 ProposalForm, 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 anypurpose. 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 herebyundertake 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 byme/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, uponthe 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.

Name of Proposer: Date:

PREMIUM DETAILS (FOR OFFICIAL USE)

Basic Premium' S$ 1 1

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

S$ 1 I

GST: [ssLess: % No Claim Discount

Add: Loyalty Home Cover @ $101.65 (with 7% GST)Total Premium Payable: [ssLess: Off-Peak Car Discount

Excess: [ssAdd: Fixtures and Accessories

Add: Others

FOR OFFICIAL USEProducer AHA- CSGAHA - Underwriter

Sigl1~ture& Dat~

Underwritten by

American Home Assurance Company, Singapore BranchIncorporated in the United States with liability limited. Signature s Date Signature & Date