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Owner Information
Ownership * : Individual
Category * :
Title * :
Full Name * :
Full Name
Please enter your Full Name as displayed on MyKAD.
 
Company Name * :
Company Name
Please enter your Company Name as like the example below.
Example: MyEG Services
Example: Global Services
 
NRIC (new IC) * :
NRIC (new IC)
Examples of acceptable formats:
Example 1: 800620125177
Example 2: 7609121234560
 
Company Registration No. * :
Company Registration No.
Examples of acceptable formats:
Example 1: H1234567
Example 2: S1234567B
 
Old IC/Army/Police No./Passport No. :
Old IC/Army/Police No./Passport No.
Examples of acceptable formats:
Example 1: E7849443
Example 2: F1928367
 
Date of Birth * :
Gender * : Male       Female    
Organization Type * : Company    Society / Local Government Council
Marital Status * : Single     Married     Divorcee
Nationality * :
Driving Experience * : year(s)
Driving Experience
Examples of acceptable formats:
Example 1: 5
Example 2: 10
Example 3: 14
 
Occupation * :
Vehicle No. * :
Vehicle No.
Examples of acceptable formats:
Example 1: ABC1234
Example 2: BJA123T
Example 3: SAA333
 
I hereby confirm that this is a private car and registered in Peninsular Malaysia only.
Address * :
Postcode * :
City * :
State * :
Contact No. * :
(Mobile)
Contact No. - Mobile
Example of acceptable formats:
Mobile: 0163156089
Home: 0370818900
Office: 0370818900
 
(Home)
Contact No. - Home
Example of acceptable formats:
Mobile: 0163156089
Home: 0370818900
Office: 0370818900
 
(Office)
Contact No. - Office
Example of acceptable formats:
Mobile: 0163156089
Home: 0370818900
Office: 0370818900
 
Email * :
Email
Examples of acceptable formats:
Example 1: sidhu@yahoo.com
Example 2: john@gmail.com
Example 3: myeg@myeg.com.my
 
Declaration
DECLARATION:
By clicking the 'PROCEED' button, I hereby declare that all statements given in this online application are complete and true. This declaration shall form the basis of the contract between me and Zurich Takaful Berhad.