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

Spouse

 

 

Paid Child 1

 

Paid Child 2

 

Paid Child 3

 


 

3. Details of Insurance

 

 

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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