APPLICATION FOR JUVENILE PERSONAL ACCIDENT INSURANCE All information entered is strictly kept confidential  (Child age 0 to 15)

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Payor's Name:
Payor's Sex:	----- Male Female
Marital Status of Payor:
Relationship to child:
Payor's Date of Birth:	Day 12345678910111213141516171819202122232425262728293031------Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ------Year 19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982------
Payor's NRIC No:
Payor's Health condition:	Healthy (Please state material facts regarding your health, if not healthy or having physical impairment).
Payor's Occupation:
Child's Full Name:
Child's Sex:	----- Male Female
Child's Date of Birth:	Day  12345678910111213141516171819202122232425262728293031------ Month  Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ------  Year  1986198719881989199019911992199319941995199619971998199920002001------
Child's IC No (Birth Cert No):
Child -  left or right-handed?	Right-handed   Left-handed   Not known
Child's Health condition:	Healthy (Please state material facts regarding your child's health, if not healthy or having physical impairment).
Budget per year RM:
Amount of coverage needed RM:

Contact tel. number: Email address: Residence 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