Statement pursuant to Section 25(5) of the Insurance Act, you are to disclose in this form, fully and faithfully, all the facts that you know or ought to know, otherwise this Policy issued hereunder may be void.

Applicant’s Particulars

Mailing Address
Driving Experience
No Claim Discount
Claim Experience
Existing Insurer

Your Vehicle



I understand submission of this electronic application form does not constitute to an automatic confirmation of insurance cover. 


I hereby declare that the above statements and particulars are complete and correct and that no facts have been suppressed or mis-stated. I agree that this proposal shall form the basis of the contract between me and the Company. 


I am aware that I can seek advice from a qualified advisor before making a commitment to purchase the product. In the event that I choose not to seek advice from a qualified adviser, I take sole responsibility to ensure that this product is appropriate to my financial needs and insurance objectives.


I acknowledge and agree that UOI may collect, use, disclose, transfer my/our personal data for the Purposes stated in UOI's Privacy Notice which can be found at


I further acknowledge by providing personal data relating to a third party (eg. Information of my dependent, spouse, children, parents and/or employees), I represent and warrant that the consent of that third party has been obtained for the collection, use and disclosure of the personal data for the Purposes stated in UOI's Privacy Notice. 


I am aware that UOI may disclose personal data collected to its third party service providers or agents (including lawyers/ law firms), which may be sited outside of Singapore, for one or more of the above Purposes, as such third party service providers or agents, if engaged by UOI, would be processing the personal data for UOI for one or more of the above Purposes. This may include disclosure to industry association.