Main Policyholder's Details

Campaign ID (leave it blank if not applicable)
 
Start Coverage on... Calendar (renewable annually)
 
Name as per NRIC
   
NRIC - -
   
Nature of Work
   
Contact No: (e.g: 012-1234567)
   
Email:
   
Mailing Address:
Postcode

Main Policyholder's Nomination Details

Name as per NRIC
   
NRIC - -
   
Relationship (e.g. Spouse)
   
Mailing Address:
   

 

Insured Spouse's Details
Spouse's Name
   
NRIC - -
   
Nature of Work
 

Spouse's Nomination Details
Name as per NRIC
   
NRIC - -
   
Relationship (e.g. Father)
   
Mailing Address:
   

 

Insured Children's Details (if any)

1st Child's Name
   
NRIC - -
   
 
   
2nd Child's Name
   
NRIC - -
   
 
   
3rd Child's Name
   
NRIC - -
   
* 3rd child coverage is free
 
 
   
4th Child's Name
   
NRIC - -
   
* Additional premium required. Refer to premium table.

 

All payments are made directly to
the underwriting Insurance Company.

RM284.00
(inclusive of stamp duty)

 Benefits (RM)

Silver
  Accidental Death & Disablement
200,000
  Total Permanent Disablement
300,000
  Medical Reimbursement
3,000
  Hospital Income (max 100 days)
100
  Inconvenience Allowance (>15 days)
10,000
 
 
Free Bonus Inclusions
 
  Death Benefit due to Dengue Fever
20,000
  Personal Liability
50,000
  Purchase of Prosthesis / Wheelchair
1,000
  Kidnap Benefit
25,000