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Policy Holder Information

Note: all fields are mandatory unless otherwise specified

I am applying:
Please select an option

Policy Holder Name:
Please enter the name of the Policy Holder or if joining an Employer Policy the name of your Employer.

Please enter the name of the Policy Holder or if joining an Employer Policy the name of your Employer.

Policy Holder Name
Enter the policy holder name

The name of the owner of the policy, this could be a family member or the name of your employer.

Policy Holder Information
Input Valid formats:

Enter the policy holder email

Select the effective date

Address
Please enter your address.

Personal Information

Please enter information of insured persons.

Enter a first name

enter family name

Enter insured person's email

Input Valid formats:

Enter your occupation and job title

Select the gender

Invalid Input

Select the relationship

Enter the Passport/Government ID Number

Select the Country of Passport

Select a Country of Residence

Enter insured person's address

Sum to be Insured and Beneficiary Information

Invalid Input

Invalid Input

Enter the Passport/Government ID Number

Select the Country of Passport

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Applicant Medical and Lifestyle Questionnaire

Do you have any other Personal Accident Insurance ?

Please select Yes or No

Do you have any other Personal Accident Insurance? Life Assurance? If so, please state name of insurance company and amount of Sum Insured.

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Do you travel ?

Please select Yes or No

If so, please indicate the average number of trips per year and the usual destinations.

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Do you play sports ?

Please select Yes or No

Do you play sports? Ride a motorcycle? Fly, other than as a fare-paying passenger? Please give details.

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Do you have any physical defect or infirmity of any kind, or any serious defect of sight or hearing or any chronic ailment?

Please select Yes or No

Please describe your physical defect ?

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Have your ever suffered any serious accidents ?

Please select Yes or No

Have your ever suffered any serious accidents during the past 5 years which have required medical treatment?

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Have you ever been declined deferred or accepted ?

Please select Yes or No

Have you ever been declined, deferred, or accepted only on special terms for Life or Accident Insurance, or has any company cancelled or declined to renew your policy, or imposed special terms?

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Have you ever made a claim under an Accident policy?

Please select Yes or No

Please provide further information about this claim

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Confirmation of Application Details

I/WE hereby apply for a policy to be based on the above statements and declare that, to the best of my/our knowledge and belief, all answers to the foregoing questions are correctly and accurately recorded, and that they are full, complete and true.

Please confirm

I/WE declare that the Insured Person is in good health; that there are no circumstances connected with the stated occupation(s), activities or pursuits which render me/us particularly liable to injury; have temperate habits; am/are not contemplating any hazardous undertaking.

Please confirm

I/WE have not concealed any circumstance(s) that ought to be known to the insurers.

Please confirm

I/WE agree that this proposal and declaration shall be the sole basis of the Contract between the applicant and PACIFIC CROSS INSURANCE COMPANY LIMITED.

Please confirm

Name of the person who completed the application

Enter your name

Broker Name or Number (if applicable):

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Date of Application

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