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Employer's Particulars

Salutation : *
Name of Employer : *
NRIC : *	(SxxxxxxxA)
E-mail : *
Address : *

Country : *
Postal : *
Contact Person :
Phone No. : *
Fax No. :

Maid's Particulars

Name of Maid : *
Date of Birth : *	(dd-mm-yyyy)
Nationality : *
Passport No. : *
Work Permit No. : *
Effective date : *	(dd-mm-yyyy) ( For renewal case, please follow work permit expiry )

Plan Selection

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Lonpac Insurance, its group companies and/or business partners may contact me/us to share information about products and services from Lonpac by post, e-mail and
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