Singapore insurance agency

Singapore Investment, Insurance and Financial Planning
SkcAgency.com

STATEMENT PURSUANT TO SECTION 25(5) OF INSURANCE ACT, CAP.142 (OR ANY SUBSEQUENT AMENDMENTS THEREOF)
You are to disclose in this proposal form, fully and faithfully all the facts which you know or ought to know in respect of the risk that is being proposed, otherwise the policy issued hereunder may be void.

Particulars of Proposer/Life Assured

Name of Proposer (name as shown in NRIC):

Date of Birth:

NRIC No.:

Gender: Female Male

Email:

Contact: (h/pgr)

(o/hp)

Address of Proposer:

Particulars of Life Assured (If other than the proposer)

Name of Proposer (name as shown in NRIC):

Date of Birth:

NRIC No.:

Gender: Female Male

Email:

Contact: (h/pgr):

(o/hp):

Relationship To Proposer:

Occupation of Life Assured:

Details of Insurance Required

Period of Insurance (Both dates inclusive) From To (dd/mm/yyyy)

Choice of Plan	Plan 1	Plan 2	Plan 3
- Death	$50,000	$100,000	$200,000
- Total Permanent Disablement	$50,000	$100,000	$200,000
- Temporary Disablement	$50 per day	$100 per day	$200 per pay
- Medical Expenses	$3,000	$5,000	$5,000
Please tick only one
Increased Sum Insured - Death & Total Permanent Disablement (Per $50,000, applicable to Plan 3 only)			$
Extended Coverage - Motorcycling Risk (additional premium: 25%)	Yes No

Other Particulars of Life Assured

Are you now insured or proposing to insure against accidents or sickness? If "Yes", with which company or companies, and for what amount?	Yes No
Do you suffer from any physical defect or infirmity or disease of any kind? If "Yes", please give details.	Yes No
Do you engage in any hazardous sports or activities? If "Yes", please give details.	Yes No
Have you sustained any accidents during the past five years? If "Yes", please give details.	Yes No
Have you ever been declined or accepted on special terms for Life, Accident or Medical Insurance or has any Company ever cancelled or refused to renew your Policy or desired to amend the conditions or benefits? If "Yes", which Company or Companies and when?	Yes No
How much is your average monthly earnings?	$

Declaration of Proposer

I hereby declare that the answers and statements given above are true and correct and I have not witheld any material information regarding the Proposal. I further agree that the Proposal and Declaration shall be the basis of the Contract to be made between me and NTUC Income.

Signature of Proposer:

Date:

IMPORTANT
1. Please note that the liability of NTUC Income does not commence until this proposal has been accepted by NTUC Income and the premium paid.
2. Please do not leave any answer blank. Fill “NIL” or “NA” where applicable.
3. The policy will carry a Premium Warranty Clause which requires the premium to be paid in full within a specific period failing which there would be no liability under the policy.
4. Please note that the minimum premium payable is S$35.