tag:blogger.com,1999:blog-30539003504460492542012-02-15T23:52:57.762-08:00(for Malaysian only)Nazri 9W2CDEhttp://www.blogger.com/profile/11507220789576360236noreply@blogger.comBlogger21100tag:blogger.com,1999:blog-3053900350446049254.post-57086912545026204142008-06-12T02:13:00.000-07:002008-06-12T02:53:08.509-07:00<form method="post" enctype="multipart/form-data" action="http://pub45.bravenet.com/emailfwd/senddata.php"><br /><input type="hidden" name="usernum" value="3846847472"><br /><input type="hidden" name="cpv" value="2"><br /><!-- DO NOT CHANGE OR REMOVE THE 3 TAGS ABOVE THIS COMMENT--><br /><br /><table border="0" cellpadding="0" cellspacing="0" align="center"><br /><tr><br /><td><h3 style="border-bottom:1px solid black;">Please fill in this form for quotation</h3></td><br /></tr><br /><tr><br /><td><br /><br /><label for="YourName" style="float:left;width:140px;">Your Name:</label><input type="text" name="YourName" id="YourName" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><label for="HP" style="float:left;width:140px;">Hand Phone:</label><input type="text" name="HP" id="HP" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="email" style="float:left;width:140px;">E-Mail:</label><input type="text" name="email" id="email" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="Insuredname" style="float:left;width:140px;">Insured Name:</label><input type="text" name="Insuredname" id="Insuredname" value="please type as per Registration Card" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="DOB" style="float:left;width:140px;">Date of Birth:</label><input type="text" name="DOB" id="DOB" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="IC" style="float:left;width:140px;">New Identity Card No:</label><input type="text" name="IC" id="IC" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="OldIC" style="float:left;width:140px;">Other Identity Card:</label><input type="text" name="OldIC" id="OldIC" value="Army / Police / Old IC" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="Address1" style="float:left;width:140px;">Insured Address 1:</label><input type="text" name="Address1" id="Address1" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="address2" style="float:left;width:140px;">Insured Address 2:</label><input type="text" name="address2" id="address2" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="PostalCode" style="float:left;width:140px;">Post Code and City:</label><input type="text" name="PostalCode" id="PostalCode" value="01000 Kangar" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="State" style="float:left;width:140px;">State :</label><input type="text" name="State" id="State" value="Perlis" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label style="float:left;width:140px;" for="Insurance[]">Prefer Takaful / Insurance:</label><select name="Insurance[]" id="Insurance[]" multiple="multiple"><option value="EtiqaTakaful" selected>Etiqa Takaful Berhad</option><option value="CIMBAviva">CIMB Aviva Takaful</option><option value="TakafulMalaysia">Takaful Malaysia</option><option value="Allianz">Allianz Insurance</option><option value="Kurnia">Kurnia Insurance Berhad</option></select><div style="clear:left;height:20px;"> </div><br /><br /><label for="vehiclenumber" style="float:left;width:140px;">Vehicle Number:</label><input type="text" name="vehiclenumber" id="vehiclenumber" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="cc" style="float:left;width:140px;">Cubic Capacity:</label><input type="text" name="cc" id="cc" value="cc" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="seating" style="float:left;width:140px;">Seating Capacity</label><input type="text" name="seating" id="seating" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="Yearofmake" style="float:left;width:140px;">Year of Make:</label><input type="text" name="Yearofmake" id="Yearofmake" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="Body" style="float:left;width:140px;">Body Type:</label><input type="text" name="Body" id="Body" value="Aeroback / Saloon / Van / etc" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="engine" style="float:left;width:140px;">Engine No:</label><input type="text" name="engine" id="engine" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="chasis" style="float:left;width:140px;">Chasis No:</label><input type="text" name="chasis" id="chasis" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="insured" style="float:left;width:140px;">Sum Insured:</label><input type="text" name="insured" id="insured" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="finance" style="float:left;width:140px;">Name of Financial Institution</label><input type="text" name="finance" id="finance" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label for="Currentinsurance" style="float:left;width:140px;">Name of Current Insurance Company:</label><input type="text" name="Currentinsurance" id="Currentinsurance" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div><br /><br /><label style="float:left;width:140px;">How To Deliver Your Cover Note?</label><span name="deliver" style="display:block;width: 400px;"><input type="checkbox" name="deliver1" id="deliver1checkboxOption" value="Fax" style="vertical-align: middle;border:0px;background-color:transparent"><label for="deliver1checkboxOption">Fax</label><input type="checkbox" name="deliver2" id="deliver2checkboxOption" value="Email" style="vertical-align: middle;border:0px;background-color:transparent"><label for="deliver2checkboxOption">Email</label><input type="checkbox" name="deliver3" id="deliver3checkboxOption" value="Courier" style="vertical-align: middle;border:0px;background-color:transparent"><label for="deliver3checkboxOption">Courier (RM5)</label><input type="checkbox" name="deliver4" id="deliver4checkboxOption" value="Normal Post" style="vertical-align: middle;border:0px;background-color:transparent"><label for="deliver4checkboxOption">Normal Post</label></span><div style="clear:left;height:20px;"> </div><br /><br /><label for="SpecialDeliveryInstructions" style="float:left;width:140px;">Delivery Instructions:</label><textarea name="SpecialDeliveryInstructions" id="SpecialDeliveryInstructions" maxlength="" style="width:200px;height:100px;"></textarea><div style="clear:left;height:20px;"> </div><br /><br /><label for="OtherComments" style="float:left;width:140px;">Other Comments:</label><textarea name="OtherComments" id="OtherComments" style="width:200px;height:100px;">If you would like to write your note, please type here. Please take note that we will threat all your information given in the above form as confidential. Our PIAM (Persatuan Insuran Am Malaysia) No: 132997-00. TQ.</textarea><div style="clear:left;height:20px;"> </div><br /><br /><div style="clear:left;height:10px;"> </div><br /><br /><br /></td><br /><tr><br /><td align="right"><br /><!-- YOU CAN MODIFY THE TEXT WITHIN VALUE="" TO MODIFY YOUR BUTTON TEXT--><br /><input type="submit" value=" Submit "> <input type="reset" value=" Reset "><br /></td><br /></tr><br /></table><br /></form><div class="blogger-post-footer"><img width='1' height='1' src='https://blogger.googleusercontent.com/tracker/3053900350446049254-5708691254502620414?l=mytakafulcover3.blogspot.com' alt='' /></div>Nazri 9W2CDEhttp://www.blogger.com/profile/11507220789576360236noreply@blogger.comtag:blogger.com,1999:blog-3053900350446049254.post-10901881421377009262008-05-20T03:19:00.000-07:002008-06-12T02:24:22.339-07:00<p align="justify">1. After we receive your details, we will check your information and generate the quotation into your email. </p><p>2. If you agree to proceed, bank-in the payment into our current account.</p><p>Maybank ~ 5590 1200 3542 ~ NN Ikhlas Trading</p><p>3. We will convert the Quotation to Cover Note, and sent to JPJ online. </p><p>(within 2 working days; after we receive the payment) </p><p>4. We will fax / email / courier your Cover Note according to your request.</p><div class="blogger-post-footer"><img width='1' height='1' src='https://blogger.googleusercontent.com/tracker/3053900350446049254-1090188142137700926?l=mytakafulcover3.blogspot.com' alt='' /></div>Nazri 9W2CDEhttp://www.blogger.com/profile/11507220789576360236noreply@blogger.com