Application for Life Insurance/Investment-linked plan All information entered is strictly kept confidential.

Type of  Insurance Need:	Select one Business Contingency Fund Cash Fund for next 2 generations Critical Illness - Classic HealthGuard Critical Illness - Healthguard 55 Disability Fund Education Fund (Please go to Juvenile appln. form) Endowment Policy Family Protection Final Expenses Fund Hospitalization Expenses Fund Huge Protection on HLV at minimal cost Investment-linked (Annual payment) Investment-linked (one-time payment) Mortgage Insurance with Premium Refund Saving for Emergency Use Saving & Protection  (No dividend participation) Saving & Protection (With dividend participation) Saving for Retirement Yearly Renewable Term plan (No cash value)       Juvenile appln. form
Additonal Benefits desired:	Accidental injury   Hospitalization   Critical Illness   Family Income
To include Additional Benefits for:	Insured only   Spouse   Children
Spouse date of birth (if additional benefits for spouse is required):	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 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 1985 1986 ------
Full name of Proposer:
Insured's gender:	------ Male Female
Insured's Race:
Insured's Height ( ft & in or cm ):
Insured's Weight ( lbs & oz or kg ):
Marital status:	Single Married Widowed Divorced ------
Insured'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 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 1985 ------
Insured's IC No.:
Residence Address:
Office Address:
Smoker?:	Yes         No
Health condition:	Healthy (Please state material facts regarding your health, if not healthy or having physical impairment).
Occupation (exact duties):
Employer's Name:
Employer's nature of business:
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
Amount of coverage RM:
Do you contemplate to engage in any private flying or hazardous sports?	No    Yes
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