HONG LEONG ASSURANCE Services Guide (Please Show)
Hong Leong Assurance Proposal Form
Online proposal form for life assure
POLICY OWNER NAME
*
POLICY OWNER NRIC
*
NRIC (Front)
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NRIC (Back)
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Marital Status
Single
Married
Windowed
Divorced
Phone Number
*
Email
*
example@example.com
Smoker
*
Non smoker
Non smoker
Yes , smoker
if Smoker , how many a day
Mailing Address same as IC Address
*
Yes
No
If No , please entry Mailing address
Mailing Address
If Different with IC Copy
Name Card (Front & Back)
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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
*
Number
*
Health Details
Height
*
CM
Weight
*
KG
Any Health Issues
*
Yes
No
Any Health issues
If Yes, Please write .
Proposal Details
Credit Card , Child Details , Nomination , Trustee , Contingent Owner
Payment Details
Payment Details
C.C
Mode of Payment
Yearly
Semi-Annual
Quarterly
Monthly
Premium
CC Owner Signature
Life Assured / Children ( If Policy Owner not the same person )
Life Assured / Children
If have Policy Owner / Payor
Life Assured / Child Name
Life Assured / Child NRIC
Life Assured / Child NRIC (Front & Back)
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Height
Weight
Life Assured / Children (Age12 & Above) Signature
Nominee Details
Nominee Details
Nominee 1 Name
Nominee 1 NRIC
Occupation
Company Name
Relationship & %
Contact Number
Nominee 1 IC (Front & Back)
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Nominee 2 Name
Nominee 2 NRIC
Occupation
Company Name
Relationship & %
Contact Number
Nominee 2 IC (Front & Back)
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Nominee 3
Nominee 3 NRIC
Occupation
Company Name
Nominee 3 Relationship & %
Contact Number
Nominee 3 IC (Front & Back)
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Nominee 4
Nominee 4 NRIC
Occupation
Company Name
Nominee 4 Relationship & %
Contact Number
Nominee 4 IC (Front & Back)
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Trustee / Contingent Owner
TRUSTEE / CONTINGENT OWNER
TRUSTEE NAME
TRUSTEE NRIC
Occupation
Company Name
Contact Number
TRUSTEE NRIC (Front & Back)
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TRUSTEE SIGNATURE
CONTINGENT OWNER NAME
CONTIGENT OWNER NRIC
CONTINGENT OWNER (Front & Back)
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CONTINGENT OWNER SIGNATURE
Politically Exposed Person Declaration Form
Do you Hold, or has previous held or is being considered for a prominent public position
Yes
No
If , Yes please elaborate
Does any of your immediate family members/ close associates hold, or previously held or is being considered for prominent public position
Yes
No
If , Yes please elaborate
Name / close associates , Position Held , Numbers of Years , Relationship
Politically Exposed Person Declaration Form
Policy Owner/ Life Assured Signature
CFF Form Signature
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Plan Details
Plan
HLA Life Essential
HLA MediStarter
HLA CompleteCover
HLA Wealth Gain/Grow Plus
HLA Wealth Booster Plus
HLA Asset Secure
HLA Prime Protect
HLA Prime Protect Plus
HLA Prime Protect Gold
HLA Medglobal
Other
Sum Assured
Premium
Riders
Medishield III
Accident Death
Disability Lump Sum Rider
Personal Accident
CI Care (48 CI)
Total CI Care
CI Care Plus (48 + 22)
Junior CI care
CIWP
LCWP
HLA Medglobal
PR
CongenitalCare Rider
Other
Others Riders
MS2MEMB , CI , CIWP , PA , CPA , LUMP , PR , LCWP
Mode of Payment
Yearly
Semi-Annual
Quarterly
Monthly
AGENT DETAILS
Agent Name
LEE WEI CHUEN
ANG KEEN KIT
CHEW SOOK YING
CHIN KAI YI
HO KA MAN
HON CHEE KEONG
KEE ZHENG DING
KOK FONG SIEW
LEE JIN CHUEN
LIM CHIN
MAH THIAN ENG
PANG MIN KEAT
PUAH EE CHIEW
SHIRREENA YEOH YEE PHING
TAN XIN LE
TAN SHEING KUANG
TING BAO LING
WONG JEE WEI
YAP CHUN LIANG
Advisor
AGENT CODE
AGENT EMAIL
example@example.com
Submit Proposal
AGENT Remark
Any Remark
DateTime
Should be Empty: