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.

RM659.00
(inclusive of stamp duty)

 Benefits (RM)

Gold
  Accidental Death & Disablement
300,000
  Total Permanent Disablement
450,000
  Medical Reimbursement
4,000
  Hospital Income (max 100 days)
200
  Inconvenience Allowance (15 days)
10,000
 
 
Free Bonus Inclusions
 
  Death Benefit due to Dengue Fever
30,000
  Personal Liability
100,000
  Purchase of Prosthesis / Wheelchair
1,000
  Kidnap Benefit
25,000