APPLICATION FOR GROUP INSURANCE
All information entered is strictly kept confidential
.
Classic Group Care
Corporate PA
Hospitalization Card
* Required fields
Company's name:
*
Type of Insurance required:
*
Hospitalization card
Accident
Critical illness
Group Term Life
Proposer's address:
*
Nature of Business:
*
E.g. Mould manufacturing factory, toy factory, electrical applicances manufacturer, brick factory, Motor vehicle repair workshop, etc.
Total no. of employees in company:
*
------
5 to 10
11 to 20
21 to 30
31 to 50
51 to 100
101 to 200
201 to 300
301 to 500
501 to 1000
Above 1000
Total no. of employees to be insured:
*
------
5 to 10
11 to 20
21 to 30
31 to 50
51 to 100
101 to 200
201 to 300
301 to 500
501 to 1000
Above 1000
Type of employees to be insured:
*
Period of insurance required:
(dd/mm/yy)
Contact tel. number:
*
Best time to call you:
*
(Please select a Time)
Before 7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
After 7.00pm
Email address:
*
Person to contact:
*
Position of person to contact:
*
Our representive will keep in touch with you when we receive your application. Thanks.
If you have any query, please use our
Enquiry
form,
E-mail
us or call
012-5158027