APPLICATION FOR EDUCATION/JUVENILE POLICY QUOTATION All information entered is strictly kept confidential   (Child's age 0 to 15)

Payor's name:
Payor's Sex:	----- Male Female
Marital status of Payor:	Married   Widowed   Divorced   Single
Relationship to child:
Payor's Date of Birth	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ------ Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ------ Year 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 ------
Payor's NRIC No.:
Payor's health condition:	Healthy (Please state material facts regarding your health, if not healthy or having physical impairment).
Occupation of Payor:
Budget per month RM:	-------- RM50 RM60 RM70 RM80 RM90 RM100 RM150 RM200 RM250 RM300 RM350 RM400 RM500 RM600 RM700 RM800 RM900 RM1000 RM1,500 RM2,000 RM3,000 Other amount, please specify at box on right

When should the policy mature?	At child's age     17 18 19 20 21 22 23 24 25 ------
Additonal benefits for Child:	Hospital & Surgical Benefits  Daily Hospital Benefit  Accident Benefits   Critical Illness   Juvenile P/accident
Child's name:
Child's Date of Birth:	Day  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ------ Month  Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ------   Year  1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 ------
Child's Sex:	----- Male Female
Child's Health:	Healthy (Please state material facts regarding health of child, if there is health/physical impairment).
Contact tel. number:
Email address:
Residence Address:
Person to contact:
Please check to see that your form is duly completed before you submit.  Thanks.
If you have any query, please use our  Enquiry  form,  E-mail  us  or call  012-5158027