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Request for motor car comprehensive insurance
*
Indicates required field
Registered Owner's Name
*
First
Last
Contact Number
*
Email
*
Make/Model
*
Ex. Toyota Vios J
Year Model
*
ex. 2005
Transmission
*
Manual
Automatic
Please select one
Fuel
*
Gasoline
Diesel
Amount Insured
*
Indicate the value of the car today. Please use comma ex. 750,000
with Act of Nature?
*
YES
NO
Mortgagee Bank
*
For additional information, please type it here.
*
Submit
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