Application for Classic HealthGuard                                     Plan & Benefits
Entry age: 6 months to 60 years (Renewable to Age 65).  All information entered will be strictly kept confidential.
Full name of Assured:
Plan applied for: Plan 1 RM30,000   Plan 2 RM50,000   Plan 3 RM100,000   Plan 4 RM200,000
Sex:
Race:
Marital status:
Height ( ft & in or cm ):
Weight ( lbs & oz or kg ):
Proposer's Date of Birth: Day    Month    Year
New IC No.:
Residence Address:
Office Address:
Health condition:
Occupation:
Any other particulars:

Contact tel. number:
Best time to call you:
Email 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