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To obtain cover, simply use below application form, complete with your details and the section you may need or call us on +84 (08) 3514 7969 Ext 132 or email us at
[email protected]
for further advice!
A- HEALTHCARE AND TERM LIFE INSURANCE
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Date of Birth
*
Nationality
*
Occupation
*
Gender
*
Male
Female
Pre-Existing Medical Conditions [if any]
*
Weight/Height and/or Body Mass Index
*
Other
*
Smoker
Non-Smoker
Comment
*
B - HOMECARE NSURANCE
Insured Premises
*
Sum Insured/ Limit
Building
*
Portable Items (If Any)
*
Content
*
Comment
*
Do you have a mortgage over your building?
*
Yes
No
If yes, please provide Bank/Mortagee details
*
Grade
*
I
II
III
IV
Building Age
*
Under 25 year
Over 25 year
Loss/Damage occurred
*
Fire
Water leakage
Theft
No
Type
*
Apartment
Villa
Dwelling-house
The Insured is:-
*
Owner Occupied
Tenant
Accessible Road Condition
*
Under 4m width & over 100m length to the main road
Other
Have you previously purchased a Home Insurance
*
Yes
No
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