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Please complete the form below for a quote and our friendly staff will get back to you as soon as possible. Thank you.

1. Particulars of Policyholder

Name *

NRIC/FIN *

Date of Birth *

I am a *

Marital Status *

Gender *

Unit Number *

Street *

Postal Code *

Email *

Contact No. *

+65

Occupation *

Annual Income *

2. Particulars of Dependants to be Insured

Spouse

Name

NRIC/FIN

Date of Birth

Gender

Occupation

Annual Income

Paid Child 1

Name

NRIC/FIN

Date of Birth

Gender

Paid Child 2

Name

NRIC/FIN

Date of Birth

Gender

Paid Child 3

Name

NRIC/FIN

Date of Birth

Gender

My child(ren) is/are unmarried and between 15 days to 18 years old or up to 25 years old and studying full-time.

Yes

3. Details of Insurance

Period of Insurance, 1 Year From *

Core Plan

Add-on 1: Increase in Sum Insured for Accidental Death/Permanent Disablement

Add-on 2: Weekly Benefit for Temporary Disablement

Add-on 3: Daily Hospital Cash Allowance

Add-on 4: Health Care Assistance for Serious Injury

Add-on 5: Recovery Support for Serious Injury

Add-on 6: Lifestyle Protection

Add-on 7: Dependant Cover

4. Declaration

I/We confirm that the above information are complete and true and declare that (Please tick):

1. I/We are not aware of any circumstance which is likely to lead to a claim under this policy.

2. I/We have not made any claims for bodily injury or had been declined or accepted on special terms under a similar personal accident insurance in the last 2 years.

3. I/We do not intend to reside outside Singapore for more than 182 days.

4. I/We accept that the policy will not pay for any injury which arises from high risk occupations that are listed in the Policy wordings.