Insured's Details

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



Nomination Details

1st Nominee
Name as per NRIC
   
NRIC - -
   
Relationship (e.g. Spouse)
   
Share Percentage % (100% if there's no second nominee)
   
Mailing Address:
   
 
 
2nd Nominee (if any)
Name as per NRIC
   
NRIC - -
   
Relationship (e.g. Spouse)
   
Share Percentage % (100% if there's no second nominee)
   
Mailing Address:



All payments are made directly to
the underwriting Insurance Company.

RM324.00
(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