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Personal Accident Request Form

Personal Accident Insurance Request Form
Name
Email
NRIC (optional)
Date of Birth (Day/Month/Year)
Sex
Occupation, Designation
Contact No.
Plan Selection

Click here for plan summary.
If you want to customize, please
send us your requirements

Remarks If the following questions apply to you or the Life to be Insured,
please provide us with the details below.
Kindly use the text box to add in details that you want us to know
and pay attention to. Thank you.

1. Do you suffer any physical impairment or deformity or
illness of any kind?

2. Do you engage in any hazardous sports that are likely to
cause bodily injury?

3. Did you sustain any injury as a result of an accident
over the past 5 years?

4. Has any previous applications for insurance been declined
or accepted at other than normal terms by any
insurance company(ies)?

Statement pursuant to Section 24(4) of the Insurance Act (Cap 142) or any subsequent
amendments thereof, you are to disclose in this enrolment form, fully and faithfully,
all the facts which you know or ought to know in respect of the risk that is being proposed,
otherwise, the policy issued hereunder may be void.