Y13899 262444 GE AccidentCare Plus II B.ai - Great Eastern Life

THE GREAT EASTERN LIFE ASSURANCE COMPANY LIMITED (Reg. No. 1908 00011G)For more information, call your Distribution Representative or complete this Proposal Formand mail back to 1 Pickering Street, #13-01 Great Eastern Centre, S(048659) / Fax: +65 6327 3023Alternatively, you can also contact our Product Enquiry Line at +65 6248 2211."For GE Representatives, please direct to location faxes: GE Changi (+65 6417 5029) or GE House (+65 6333 1630)"PROPOSAL FORM FOR ACCIDENTCARE PLUS II Introducer Scheme/Worksite: Self Bank Co.Policy No.:Introducer /Worksite No.:WARNING: PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT (CAP.142), YOU ARE TO DISCLOSE IN THIS FORM FULLY AND FAITHFULY, ALL THE FACTS WHICHYOU KNOW OR OUGHT TO KNOW, OTHERWISE YOU MAY RECEIVE NOTHING FROM THE POLICY.PARTICULARS OF PROPOSERName (as shown in NRIC) Mr/Mrs/Madam/Ms/DrNRIC/Passport No.: Date of Birth: Gender: Male FemaleFIN No.: Nationality: Email Address:Residential Address (as indicated in the NRIC):Postal Code:Country of Address:Mailing Address:Care of Address: Yes No Country of Address:If the mailing address differs from residential address, please provide the reason(s)Postal Code:Contact No: (H) (O) (HP)Industry & Occupation: Occupation Class: Description of Occupation:PARTICULARS OF LIFE TO BE ASSUREDName (as shown in NRIC) Mr/Mrs/Madam/Ms/DrNRIC/Passport No.: Date of Birth: Gender: Male FemaleFIN No.:Nationality:Relationship to Proposer:MEDICAL AND UNDERWRITING QUESTIONS ON LIFE TO BE ASSUREDOccupation: Industry: Height: cm Weight: kgName of Company:Description of Occupation:Kindly indicate your Occupational Class Type: Class 1 Class 2 Class 3 Class 41. Does the Life to be assured suffer any physical impairment or deformity or illness of any kind?2. Does the Life to be assured engage in any hazardous sports that are likely to cause bodily injury?3. Has the Life to be assured sustained any injury as a result of an accident over the past five years?4. Has the application by the Life to be assured ever been declined or accepted at other than normal terms by any Insurance Company(ies) includingGreat Eastern Life?5. Does the Life to be assured have any other existing Personal Accident Policy(ies)/Rider(s) with Great Eastern Life?If ‘Yes’ to any of the above, please give details below or use a special health questionnaire (if necessary)❏ Yes ❏ No❏ Yes ❏ No❏ Yes ❏ No❏ Yes ❏ No❏ Yes ❏ NoCHOICE OF COVERAGE (Please indicate the Benefit Amount and Corresponding Premium.)A. Death (This benefit is compulsory)B. Major Permanent Disablement (Sum Assured cannot exceed that of A.)C. Other Permanent Disablement (Benefit must be taken up with B;Sum Assured cannot exceed that of B.)D. Total Disability (Weekly Benefit Insured cannot exceed 75% of the Average Weekly Earned Income or 0.5%of the Sum Assured under A, or S$500 whichever is lowest.)E. Partial Disability (Benefit must be taken up with D; Weekly Benefit Insured cannot exceed 50% of D.)F. Medical Expense Reimbursement(Limit insured cannot exceed 50% of the sum assured under A, or $50,000*, whichever is lower) IncludesMedical Expenses by Complementary Medicine Practitioner - up to 50% of Medical Expense Reimbursementlimit. Subject to a maximum of S$500 for each and every accident.G. Hospitalisation (Daily Benefit Insured cannot exceed 0.1% of the Sum Assured under A, or $300*,whichever is lower.)H. Evacuation and Repatriation (Benefit must be taken up with F)I. Mobility Aids (Reimbursement Limit Insured cannot exceed 50% of F)* On all Personal Accident Policies or Riders with the Company.@Minimum Annual Premium size is S$60.+For the calculation of Monthly Premium, multiply Total Annual Premium by 0.08583.#For the calculation of Premium inclusive of GST, multiply Total Annual Premium or Monthly Premium by the prevailing GST.Benefit AmountS$50,000Annual Premium @Add: 15% Annual Premiumfor full benefits for Motorcyclist (if applicable)Monthly Premium + (if applicable)Annual Premium inclusive of GST #Monthly Premium inclusive of GST # (if applicable)PremiumPAYMENT INSTRUCTION & AUTHORISATIONPayment method (please tick):Payment mode (please tick): Monthly YearlyNote: i) Yearly payments can be made by GIRO/credit card/cheque. Monthly payments can only be made by GIRO/credit card.ii) If you are paying by CASH, please remember to obtain a Cash Acknowledgement Receipt or Insurance Payment Slip (where applicable) from the DistributionRepresentative upon payment of premium.By Cheque(Yearly Mode Only*)By Giro (Please make out a cheque* payable to “Great Eastern Life Assurance Co. Ltd.”, for either 2 months of premiums or 1 yearly payment and mail it to ustogether with the completed ORIGINAL GIRO form attached to Customer Service)* Please make out a cheque payable to “Great Eastern Life Assurance Co. Ltd.”. Please write the name and NRIC No. of the Proposer and Life to be Assured on the reverse side ofthe cheque.By VISA/MasterCardfor (Credit Card Holdermust be the Proposer)Name of Credit Card Holder:Initial and renewal premiumsInitial premium onlyExpiryDateM M Y Y Y YFor monthly credit card payment, the initialdeduction will be for 2 months premium.NBUACCP03/14