APPLICATION FOR GOLFER'S INSURANCE All information entered is strictly kept confidential.

Full name of  Proposer:
Sex:	----- Male Female
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 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 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 1984 --------
Occupation/Profession:
NRIC No.:
Individual cover:	Yes       No
Individual & Spouse cover:	Yes       No
For Spouse cover:  Spouse name:
Spouse 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 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 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 1984 --------
Spouse NRIC No.:
Period of insurance:
Residence Address:
Please state Name & Address of Golf Club(s) of which you are a member:
DETAILS OF GOLF EQUIPMENT
(If individual value is more than RM1,000, please provide receipts).	Make of Golf Clubs: Woods: Irons: Putters: Please state number of: (i) Woods: (ii) Irons: (iii) Putters: Date of purchase: Total value: RM New or Secondhand
DECLARATIONS	(The following questions must be answered)
1. Has any insurer ever refused to accept, renew or continue your insurance cover or quoted increase rate or special terms?	Yes      No
2. Have you any physical defects or health impairments?	Yes      No
3. Have you ever sustained any accident necessitating medical attention during the past 5 years or had made any claim against any insurance company for such injury?	Yes      No
4. Have you ever sustained any loss or damage to your golfing equipment during the past 12 months or had any person claim against you for loss or damage to their property or causing bodily injuries to any third party while engaging in any golfing activities?	Yes      No
If your answer is "YES" to any of the above, please give details:
Contact telephone number:
Email address:
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