<%@ Language=JavaScript %> HS App Form BHN
   Application for Hassle-free Hospital Admission - B-HealthNet                
Entry age: 15 days to 60 years (Renewable to Age 70)  All information entered is strictly kept confidential.		 Plan features
Type of  Hospitalization Need: HN1 RM350 room      HN2 RM200 room      HN3 RM120 room      HN4 RM80 room
Full name of Proposer:
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. (Old IC:          )
Residence Address:
Office Address:
Health condition:
Occupation of proposed Insured:
Do you wish to include your family members for this cover? Yes       No   (Premium will be based on the older age of the 2 spouses)
Spouse's Date of Birth: Day    Month    Year
Other particulars:

Contact tel. number:
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