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 Proposer Employer Name (As in NRIC) * NRIC/Fin Number * Date of Birth * Gender * ---MaleFemale I am a * ---SingaporeanSingapore PRForeigner Dwelling Type * ---HDBOthers Address * Postal Code * 2. Contact Information Email * Occupation Tel (HP) * Tel (Home) 3. Details of Insurance Work Permit Type * ---New MaidRenewal MaidTransfer Maid SB Transmission No* Current Work Permit Expiry Date * Effective Date * Option to upgrade from $40,000 to $60,000 Personal Accident Coverage * : YesNo Duration of Policy * : 14 mths26 mths Additional hospital and surgical expenses (each year) ---S$5,000S$10,000S$15,000S$20,000S$25,000 Waiver * : YesNo 4. Maid's Particulars Maid Name (As in Passport) * Maid Passport No. * Maid Passport Expiry Date * Maid Nationality * ---AfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBrunei DarussalamBulgariaBurkina FasoMyanmar/BurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominican RepublicDominicaEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench GuianaGabonGambiaGeorgiaGermanyGhanaGreat BritainGreeceGrenadaGuadeloupeGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIsrael and the Occupied TerritoriesItalyIvory Coast (Cote d'Ivoire)JamaicaJapanJordanKazakhstanKenyaKosovoKuwaitKyrgyz Republic (Kyrgyzstan)LaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgRepublic of MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNepalNetherlandsNew ZealandNicaraguaNigerNigeriaKorea, Democratic Republic of (North Korea)NorwayOmanPacific IslandsPakistanPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent's & GrenadinesSamoaSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovak Republic (Slovakia)SloveniaSolomon IslandsSomaliaSouth AfricaKorea, Republic of (South Korea)South SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTimor LesteTogoTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsUgandaUkraineUnited Arab EmiratesUnited States of America (USA)UruguayUzbekistanVenezuelaVietnamVirgin Islands (UK)Virgin Islands (US)YemenZambiaZimbabwe Maid Work Permit No * Maid Date of Birth * 5. Additional Information Promotional Code How Did You Hear of Us/Find Us? * ---Social mediaRecommended by friend/familySearch engineRadioBusiness associateInternet adLink from another pageFlyer/Banner/PosterRoad ShowBloggerEmailOther Remarks 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. *indicates required field. By clicking Submit, you agree to our Privacy Policy.
