Personal Accident

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 Main Insured / Policyholder







2. Particulars of Dependants to be Insured




Paid Child 1


Paid Child 2


Paid Child 3



3. Details of Insurance


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.


5. Additional Information


I/we hereby understand that I/we need to disclose our personal data in order for Assure (Singapore) Pte Ltd to generate a quotation for me/us. I/we have read the Privacy Policy and I/we consent to the collection and use of my/our personal data in accordance with its terms and conditions. I/we agree and understand that accuracy of quotation premium is solely reliant on information provided by me/we only.



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