REQUEST FOR INSURANCE QUOTATION
PLEASE ENTER YOUR INFORMATION BELOW SO WE CAN BE IN TOUCH
SALUTATION:
*
Please Select
TAN SRI / PUAN SRI
DATUK / DATO / DATUK SRI / DATO SRI / DATIN / DATIN SRI
DR / PROF
MR / MISS / MRS / MADAM
FULL NAME:
*
GENDER:
*
Please Select
MALE
FEMALE
DATE OF BIRTH:
*
/
Day
/
Month
Year
PHONE NUMBER
*
EMAIL ADDRESS:
*
CURRENT OCUPATION:
*
PLEASE DESCRIBE YOUR CURRENT OCCUPATION:
*
ARE YOU SMOKING?
*
Please Select
YES
NO
WHAT KIND OF SMOKER ARE YOU?
*
Please Select
I'M NOT SMOKER
CIGARETTE
VAPE
CIGARETTE & VAPE
I WOULD LIKE TO REQUEST A QUOTATION ON:
*
Please Select
MEDICAL CARD (CONVENTIONAL / TAKAFUL)
SAVING & HIBAH PLANNING (CONVENTIONAL / TAKAFUL)
MORTGAGE INSURANCE (CONVENTIONAL / TAKAFUL)
PERSONNAL ACCIDIENT (CONVENTIONAL)
FIT CI (CONVENTIONAL / TAKAFUL)
MY MONTHLY BUDGET (RM)
*
MY PROPOSED HIBAH AMOUNT (RM) / SUM INSURED
*
YOUR REMARKS:
*
SUBMIT APPLICATION
Should be Empty: