DETAILS PERSON TO BE COVERED DETAILS PROPOSER

NAME : NAME :
NRIC / BIRTH CERT : NRIC / BIRTH CERT :
D.O.B : D.O.B :
GENDER : MALE FEMALE GENDER : MALE FEMALE
HEIGHT (cm) : HEIGHT (cm) :
WEIGHT (kg) : WEIGHT (kg) :
SMOKING : If yes, how many (sticks) per day? : SMOKING : If yes, how many (sticks) per day? :
MARITAL STATUS : MARRIED SINGLE MARITAL STATUS : MARRIED SINGLE
DIVORCED WIDOWED DIVORCED WIDOWED
CHILDREN : How many? CHILDREN : How many?
ADDRESS : ADDRESS :

HP NO : HP NO :
OCCUPATION DETAILS OCCUPATION DETAILS
COMPANY NAME : COMPANY NAME :
COMPANY ADDRESS / LOCATION : COMPANY ADDRESS / LOCATION :

OCCUPATION : OCCUPATION :
EXACT NATURE OF WORK : EXACT NATURE OF WORK :
MODE OF PAYMENT : Y / H / Q / M NOMINEE DETAILS
METHOD OF PAYMENT : CASH / CHEQUE / DEBIT CARD / CREDIT CARD NAME :
NAME ON CARD : NRIC :
CARD NUMBERS : ADDRESS :
VALID UNTIL :
VISA / MASTER :
BANK : TEL / HP NO. :
PLAN PERCENTAGE :
PLAN NAME : NOMINEE DETAILS
PREMIUM : RM NAME :
PRODUCT NAME : NRIC :
DEATH / TPD COVERAGE : RM ADDRESS :
CRITICAL ILLNESS COVERAGE : RM EARLY PAYOUT : YES / NO
HOSPITAL ROOM : RM
NORMAL PACK : TEL / HP NO. :
ANNUAL LIMIT : RM PERCENTAGE :
LIFETIME LIMIT : RM HEALTH
EXTENDER PACK : Any health problem? :
ANNUAL LIMIT : RM When / where it happened? :
LIFETIME LIMIT : RM Reason of the incident? :
EMERGENCY OUT PATIENT : RM How is the condition currently? :
ACCIDENTAL DEATH BENEFIT : RM CAR ASSISTANCE SERVICE
HOSPITAL INCOME BENEFIT : RM /day CAR REGISTRATION NO. :
SIGNATURE OF PERSON TO BE COVERED SIGNATURE OF PROPOSER