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 Surname * Given name * NRIC / FIN No. * Nationality * SingaporeanAfghanAlbanianAlgerianAmericanAndorranAngolanAntiguansArgentineanArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBarbudansBatswanaBelarusianBelgianBelizeanBenineseBhutaneseBolivianBosnianBrazilianBritishBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCentral AfricanChadianChileanChineseColombianComoranCongoleseCongoleseCosta RicanCroatianCubanCypriotCzechDanishDjiboutiDominicanDominicanDutchDutchmanDutchwomanEast TimoreseEcuadoreanEgyptianEmirianEquatorial GuineanEritreanEstonianEthiopianFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGreekGrenadianGuatemalanGuinea-BissauanGuineanGuyaneseHaitianHerzegovinianHonduranHungarianI-KiribatiIcelanderIndianIndonesianIranianIraqiIrishIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstaniKenyanKittian and NevisianKuwaitiKyrgyzLaotianLatvianLebaneseLiberianLibyanLiechtensteinerLithuanianLuxembourgerMacedonianMalagasyMalawianMalaysianMaldivanMalianMalteseMarshalleseMauritanianMauritianMexicanMicronesianMoldovanMonacanMongolianMoroccanMosothoMotswanaMozambicanNamibianNauruanNepaleseNetherlanderNew ZealanderNi-VanuatuNicaraguanNigerianNigerienNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPanamanianPapua New GuineanParaguayanPeruvianPolishPortugueseQatariRomanianRussianRwandanSaint LucianSalvadoranSamoanSan MarineseSao TomeanSaudiScottishSenegaleseSerbianSeychelloisSierra LeoneanSlovakianSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSpanishSri LankanSudaneseSurinamerSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadian or TobagonianTunisianTurkishTuvaluanUgandanUkrainianUruguayanUzbekistaniVenezuelanVietnameseWelshWelshYemeniteZambianZimbabweanAfghanAlbanianAlgerianAmericanAndorranAngolanAntiguansArgentineanArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBarbudansBatswanaBelarusianBelgianBelizeanBenineseBhutaneseBolivianBosnianBrazilianBritishBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCentral AfricanChadianChileanChineseColombianComoranCongoleseCongoleseCosta RicanCroatianCubanCypriotCzechDanishDjiboutiDominicanDominicanDutchDutchmanDutchwomanEast TimoreseEcuadoreanEgyptianEmirianEquatorial GuineanEritreanEstonianEthiopianFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGreekGrenadianGuatemalanGuinea-BissauanGuineanGuyaneseHaitianHerzegovinianHonduranHungarianI-KiribatiIcelanderIndianIndonesianIranianIraqiIrishIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstaniKenyanKittian and NevisianKuwaitiKyrgyzLaotianLatvianLebaneseLiberianLibyanLiechtensteinerLithuanianLuxembourgerMacedonianMalagasyMalawianMalaysianMaldivanMalianMalteseMarshalleseMauritanianMauritianMexicanMicronesianMoldovanMonacanMongolianMoroccanMosothoMotswanaMozambicanNamibianNauruanNepaleseNetherlanderNew ZealanderNi-VanuatuNicaraguanNigerianNigerienNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPanamanianPapua New GuineanParaguayanPeruvianPolishPortugueseQatariRomanianRussianRwandanSaint LucianSalvadoranSamoanSan MarineseSao TomeanSaudiScottishSenegaleseSerbianSeychelloisSierra LeoneanSingaporeanSlovakianSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSpanishSri LankanSudaneseSurinamerSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadian or TobagonianTunisianTurkishTuvaluanUgandanUkrainianUruguayanUzbekistaniVenezuelanVietnameseWelshWelshYemeniteZambianZimbabwean Marital Status * ---MarriedSingleWidowedDivorced Date of Birth * Gender * ---MaleFemale Mailing Address * Postal Code * Email * Tel (HP) * Tel (Home) Occupation Classification * ---Non-ManualManual Job Title * Annual Income * 2. Particulars of Dependants to be Insured Spouse Fullname NRIC / FIN No. Date of Birth Gender ---MaleFemale Occupation Classification ---Non-ManualManual Job Title Annual Income Paid Child 1 Fullname NRIC / FIN No. Date of Birth Gender ---MaleFemale Paid Child 2 Fullname NRIC / FIN No. Date of Birth Gender ---MaleFemale Paid Child 3 Fullname NRIC / FIN No. Date of Birth Gender ---MaleFemale My child(ren) is/are unmarried and between 15 days to 18 years old or up to 25 years old and studying full-time. YesNo 3. Details of Insurance Period of Insurance, 1 Year From * 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 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.
