Particulars of Proposer
Name (as shown in NRIC):
Date of Birth (dd/mm/yyyy):
Gender:
Female
Male
Residential Address:
Email:
Particulars of Life Insured
Name (as shown in NRIC):
Date of Birth (dd/mm/yyyy):
Gender:
Female
Male
Relationship with Proposer:
Payment Method And Mode
Premium Paymode:
$10 monthly (by GIRO only)
$100 per year
Payment Method:
GIRO
Cash/cheque
Commencement Date (dd/mm/yy):
GIRO Arrangement
Name of Bank/Branch:
Bank Account No.:
Name of Account holder:
NRIC of Account holder:
Health Questions on Life Insured
1. Have you ever suffered from or received treatment for disease of the heart or circulatory system, stroke, high blood pressure, diabetes, cancer, growth or other malignancy, kidney or bladder disorders, asthma, other respiratory disorders, liver disease,
2. Have you suffered from physical or mental impairment or deformity?
3. Have you undergone or are you undergoing any medical treatment/surgical operation?
4. Have your proposal or application for a Life or Accident or Hospital
Declaration and Authorisation
I hereby declare that the foregoing answers are true and whether written by me or by anyone else on my behalf I accept full responsibility for them; and that I have not withheld any material information; and that this assurance is to be taken out by me and the premiums to be paid thereon are to be paid by me. I agree that there shall be no liability upon Income until a policy has been issued and delivered to me and the first premium paid in full.
Signed in Singapore on the
Signature of Proposer/Insured: Signature, Name & NRIC No. of Witness:
