Enrolment

Under Section 25(5) of the Insurance Act Cap 142 or any subsequent amendment thereof, you are to disclose in this Application form, fully and faithfully, all the facts which you know or ought to know, otherwise the policy issued may be void.

No insurance shall be in force until this application has been accepted by and premium is paid in accordance to the Payment Before Cover Warranty or Premium Payment Warranty (whichever applicable) to the Company.

1. Salutation
2. First Name
3. Last Name
4. Gender
5. NRIC
6. Date of Birth
7. Nationality
8. Marital Status
9. Block / House Number
10. Unit Number
11. Street Name
12. Building / Estate Name
13. Postal Code
14. Telephone Number (H) (O) (Mobile)
15. Occupation
16. Job Industry
17. No. of Dependents
18. Education
19. Annual Income
20. Phillips Securities Representative Information (optional)
 
Premium Details
1. Plan Type
2. Insured Person
3. Payment Mode
 
Payment Details
1. Card Types
2. Card Number ---
3. Card Expiry Date
Declaration:
1) The information on this declaration is full, complete, true and correct and that nothing material has been withheld. I also agree that they be the basis of the contract between the Company and the insured person(s).
2) I understand that the Company, believing them to be such, will rely and act on them, otherwise any Policy issued will be void.
3) I understand that all Pre-Existing Conditions before the effective date of this Policy are not covered.
4) I hereby apply for the insured person(s) named above to be insured under this plan. I am authorised to act on behalf of this person(s).
5) I am aware that I can seek advice on the suitability of this product before I sign this application/proposal form. Should I choose not to, I take sole responsibility to ensure that this product is appropriate to the financial needs and insurance objectives of the insured person(s).
6) I agree that the Company shall assume no liability until full and complete information is furnished on the application.
7) I acknowledge that coverage will only commence upon full receipt of information.
   
 
   
 
 
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