Foreign Worker Medical Insurance - Liberty Insurance Pte Ltd

Statement Pursuant to Section 25(5) of The Insurance Act (Cap. 142): You are to disclose in the 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.

Company's Particulars

Company name : *

UEN : *

E-mail : *

Company Address : *

Address :

Country : *

Postal : *

Contact Person :

Phone No. : *

Business:

Worker's Particulars 1

Name of Worker : *

Date of Birth : *

Nationality : *

Passport No. : *

FIN Number : *

Effective date : *

Occupation : *

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Plan Selection

Available only to Work Permit or S Pass Holder, maximum enrolment age is 65 years old.

Basic Plan - S$60,000 medical cover with 25% co-payment - Premium : $185.30 (inc. GST)

Basic Plus Plan - S$60,000 medical cover without co-payment - Premium : $248.52 (inc. GST)

I/We certify that I/We have read and agree to the Terms and Conditions from InsureAsia.com.sg

I/We declare and warrant that: None of the Insured Member(s): (1) have had any medical claims for the past 3 years up to the inception date of the Policy; or (2) is presently seeking and/or receiving any consultation or treatment at a hospital whether or not drugs and medicine have been prescribed; or (3) have any existing condition(s) of any critical illness or dread disease (including without limitation of cancer, heart disease, stroke, liver disorder, or organ failure); or (4) have any diagnosed condition(s) or symptom(s) or ailment(s) for which hospitalisation is anticipated or pending.

I/We declared that my/our company has not been declined, refused renewal or subjected to any special condition by Liberty Insurance Pte Ltd.

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Foreign Worker Medical Insurance - Liberty Insurance Pte Ltd

Company's Particulars

Worker's Particulars 1

Plan Selection

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Foreign Worker Medical Insurance - Liberty Insurance Pte Ltd

Company's Particulars

Worker's Particulars 1

Plan Selection

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