Buy Insurance Form

Full Name As in Identity Card (IC)*
NRIC / Passport Number*
Contact Number*
Email Address*
Date of Birth*
/ /
Gender*
Male Female
Home Address*
Coverage Type*
Travel Insurance Per Trip Travel Insurance Annual Travel Insurance Domestic
Destination*
Policy Type*
Individual Couple Family
Effective Date*
/ /
Expiry Date*
/ /
Number of Adult (18-70 years)
Number of Child (30 Days - 17 years)
Number of Senior (71-84 years)
EMERGENCY CONTACT DETAILS
Emergency Contact Name*
Emergency Contact Number*
Relationship to Primary Insured *
ADD NOMINEE
Full Name as in IC
NRIC / Passport Number
Contact Number
Date of Birth
/ /
Relationship to Primary Insured
Percentage (%)