Personal Particulars

First Name*

Last Name*

Gender*

Male

Female

ID Type*

NRIC / Passport No*

Date of Birth*

Nationality*

Hidden

Nationality

Occupation*

Work Environment*

What is your marital status?*

Married

Single

Divorced

Widowed

Mobile Number*

Important notice

Statement to section 25(5) of the Insurance Act (Cap. 142). You are to disclose fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder may be void.

REGISTRATION FORM

Address

Postal Code

ZIP / Postal Code

Building Name

House No./ Blk*

Floor Level

Unit No

Street Name*

Country*