Free Term Life Insurance Form Free Term Life Insurance Step 1 of 3 33% Warning: Pursuant to Section 25(5) of the Insurance Act (Cap 142), you are required to disclose in this proposal form fully and faithfully, all the facts which you know or ought to know. If a material fact is not disclosed in this proposal, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. Please check to ensure you are fully satisfied with the information declared in this proposal.Step 1: Enter DetailsSalutation*MrMrsMdmMissDrFull Name (as per your NRIC)*Date of birth (DD/MM/YYYY)* Marital Status*DivorcedSeparatedMarriedSingleWidowedNationality*Singapore CitizenSingapore Permanent ResidentCitizenship*Please selectAfricaAlgeriaArgentinaArmenianAustraliaAustriaAzerbaijanBahrainBangladeshBelgiumBrazilBruneiBulgariaCambodiaCanadaChinaChileColumbiaCroatiaCzech RepublicDenmarkEgyptEnglandFiji IslandFinlandFranceGermanyGreeceGuamHollandHong KongHungaryIcelandIndonesiaIndiaIrelandIranIraqIsraelItalyJapanJordanKazakhstanKuwaitLaosLibyaLuxembourgMacauMaldivesMalaysiaMaltaMauritiusMexicoMonacoMyanmarFor Keyman Signatory (NB Dept)NepalNicaraguaNigeriaNorth KoreaNorwayNetherlandsNew ZealandOmanOtherPakistanParaguayPhilippinesPapua New GuineaPolandPortugalQatarRomaniaRussiaSouth AfricaSouth KoreaSloveniaSpainSri LankaSaudi ArabiaSurinameSwedenSwitzerlandSyriaTaiwanThailandTongaTurkeyUnited Arab EmiratesUnited KingdomUSAVietnamYugoslaviaZambiaCitizenship*SingaporeNRIC*Gender*MaleFemaleSmoker status*SmokerNon-SmokerEmail address* Enter Email Confirm Email Mobile Number*Home NumberOffice NumberResidential AddressBlock/House No.*Street*Unit No.BuildingCityCountry*SingaporePostal Code* Mailing address is different from residential address Mailing AddressBlock/House No.*Street*Unit No.BuildingCityCountry*SingaporePostal Code*You are applying as:*NewlywedNew parentsYou are applying as:*New parentsYour Marriage's DetailsDate of Marriage (DD/MM/YYYY)* Date of Marriage must be within 6 months from date of applicationYour Baby's DetailsFull name (as per Birth Certificate)*Date of Birth (DD/MM/YYYY)* Gender*MaleFemale*Please fill in all mandatory fields. Step 2: Declaration and Acknowledgement I am in good health and have never suffered from or received treatment for heart disease, high blood pressure, diabetes, stroke, cancer, tumours/cysts, hepatitis, paralysis, lung disease, kidney disease, HIV / AIDS or any other serious illness / physical disability. I also confirm that I have never had any diagnostic tests reported as being abnormal. This is my first application for the Free Term Life Insurance.I acknowledge receipt of all the pages of the product summary and Frequently Asked Questions for the policy and I understood the conditions under which the benefits of this plan will be payable. I declare that the information given in this proposal and any information supplied to Etiqa Insurance Pte Ltd ("Etiqa") is true and that no material fact (i.e. facts likely to influence the assessment and acceptance of this proposal) have been withheld and to the best of my knowledge and belief the information given herein is true and complete and shall be the basis of my contract with Etiqa. I understand that Etiqa only permit one plan per life insured. In the event I apply for multiple policies for Free Term Life Insurance, Etiqa will only pay a maximum of S$25,000.Submission of documents: A photographic copy of this authorisation shall be as valid as the original. I understand that the policy applied for herein shall be underwritten as a Singapore policy and be entered in the register of Singapore policies of Etiqa. This policy shall be subject to MAS guidelines, Singapore rules and law. In consideration of Etiqa considering my electronic proposal, I agree: (a) that my electronic signature on the electronic proposal for life insurance bearing my name (“my Proposal”) will be legally binding as if I had signed on the hardcopy of the Proposal; (b) to the admission, as evidence in any court of law or tribunal in Singapore, the electronic records or documents shown to me or electronically signed by me during the preparation of my proposal (the “Electronic Record”); and (c) that the Electronic Records, and any copies thereof, are admissible in any court of law in Singapore as original documents and agree not to challenge or dispute their admissibility, authenticity or accuracy in any proceedings. Data Protection I expressly authorise and consent to Etiqa, its officers, employees and representatives disclosing, at their sole discretion, any and all information relating to me, including my personal particulars, my transactions and dealings and my policies of insurance with Etiqa, to any of the following persons, whether in Singapore or elsewhere: (a) Etiqa’s holding companies, branches, representative officers, subsidiaries, related corporations or affiliates; (b) any of Etiqa’s contractors or third party service providers or distribution partners or professional advisers or representative; (c) any regulatory, supervisory or other authority, court of law, tribunal or person, in any jurisdiction, where such disclosure is required by law, regulation, judgement or order of court or order of any tribunal or as a matter of practice; (d) any actual or potential assignee(s) or transferee(s) of any rights and obligations of Etiqa under or relating to my policy or policies for any purpose connected with the proposed assignment or transfer; and (e) any credit bureau, insurer or representative, for such purpose(s) that Etiqa in its reasonable opinion considers appropriate including but not limited to the purposes of underwriting, customer servicing, investigation of Etiqa’s representatives and monitoring undesirable sales practices. By applying for and accepting this Free Term Life Insurance, I agree to receiving information, including marketing materials from Etiqa Insurance Pte. Ltd. via SMS, email or direct mailer. Step 3: Uploading of Document Please attach a copy of your NRIC. Note: Please check to ensure that you have uploaded the correct document. Please upload your document files with the following criteria: 1. File format has to be either GIF, JPG (JPEG), TIF(TIFF) or PDF 2. Maximum file size of 10MB 3. File name cannot contain spaces or symbols. (e.g. &, %, $, etc.)Attachment:*Accepted file types: jpg, gif, tif, pdf.Accepted file types: jpg, gif, tif, pdf.