HLA PROPOSAL FORM

- Hong Leong Assurance Proposal Form
  
  PROPOSAL FORM FOR LIFE INSURANCE
- POLICY OWNER NAME*
- POLICY OWNER NRIC*
- NRIC (Front)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- Marital Status
- Smoker
- NRIC (Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- Religion
- Nationality
- Nationality - others
  If your nationality is other than Malaysian
- ChineseMalayIndianOther
- Phone Number*
  
  Area CodePhone Number
- Email*
  example@example.com
- Mailing Address same as IC Address*
  If No , please entry Mailing address
- Mailing Address
  If Different with IC Copy
- Occupation*
- Yearly Income*
- Name of Employer*
- Type of Business
- Office Address
  If Different with Name card
- Direct Debit Details
  
  For Cash Rebate , Cash Payment , Dividend Pay
- Bank
- Account Number
- Bank Details Copy
  
  Browse Files
  Must Show Bank Name & Account Name & Account Numeber Cancelof
- Health Details
- Height*
  CM
- Weight*
  KG
- Any Health Issues*
- Any Health issues
  If Yes, Please write .
- Proposal Details
  
  Credit.C , Child Details , Nomination , Trustee , Contingent Owner
- Payment Details
- Bank
- YearlySemi-AnnualQuarterlyMonthly
- Premium
- C.Card Owner Signature
  
  Clear
- Life Assured / Children
  
  If have Policy Owner / Payor
- Life Assured / Child Name
- Life Assured / Child NRIC
- Life Assured / Child NRIC (Front & Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- Height
- Weight
- Life Assured / Children (Age12 & Above) Signature
  
  Clear
- Nominee Details
- Nominee 1 Name
- Nominee 1 NRIC
- Occupation
- Company Name
- Relationship & %
- Contact Number
- Nominee 1 IC (Front & Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- Nominee 2 Name
- Nominee 2 NRIC
- Occupation
- Company Name
- Relationship & %
- Contact Number
- Nominee 2 IC (Front & Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- Nominee 3
- Nominee 3 NRIC
- Occupation
- Company Name
- Nominee 3 Relationship & %
- Contact Number
- Nominee 3 IC (Front & Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- Nominee 4
- Nominee 4 NRIC
- Occupation
- Company Name
- Nominee 4 Relationship & %
- Contact Number
- Nominee 4 IC (Front & Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- TRUSTEE / CONTINGENT OWNER
- TRUSTEE NAME
- TRUSTEE NRIC
- Occupation
- Company Name
- Contact Number
- TRUSTEE NRIC (Front & Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- TRUSTEE SIGNATURE
  
  Clear
- CONTINGENT OWNER NAME
- CONTIGENT OWNER NRIC
- CONTINGENT OWNER (Front & Back)
  
  Browse Files
  Can Add Multi Photo / Files Cancelof
- CONTINGENT OWNER SIGNATURE
  
  Clear
- I hereby declare that all the information contained in this proposal is the only information given to me by the Policy Owner and Life Assured.
- Policy Owner/ Life Assured Signature
  
  Clear
- CFF Form Signature
  
  Clear

Hong Leong Assurance Proposal Form

Direct Debit Details

Health Details

Proposal Details

Payment Details

Life Assured / Children

Nominee Details

TRUSTEE / CONTINGENT OWNER

AGENT DETAILS