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Your Details


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Spouse


Are you and the persons insured now generally in good health and free from any physical defect or infirmity? If 'No', please give details.
Have you or any of the persons insured ever suffered from any sicknesses or received medical or surgical treatments during the last 5 years which have prevented you or them from attending to your or their normal occupation, pursuits or business for a period of 7 days or longer? If 'Yes', please give details.
Are you presently covered by any Personal Accident insurance? If 'Yes', Please state the amount and the name of the insurance company.
Has the insurance now proposed been declined, cancelled, refused renewal or subjected to special terms by any insurance company? If 'Yes', please give details.
Have you or any of the persons insured ever made a claim against any insurer under a personal accident policy in the last 5 years? If 'Yes', please give details.

1. First Nominee for Self    add_circle

2. Second Nominee for Self   

1. First Nominee for Spouse    add_circle

2. Second Nominee for Spouse   

I/We hereby declare that the above answers and statements are true, and that I/we have withheld no information whatever regarding this application.
I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above.
I/We hereby consent to have AXA Affin General Insurance Berhad and/or any company within the AXA Group of Companies and/or any of its associated companies, within or outside Malaysia, process my/our Personal Data for the purposes and to the extent stated in the Data Privacy Notice.
I/We would like to receive special offers, promotions, surveys and information related to the insurance products, events and services of AXA Affin General Insurance Berhad and/or any company within the AXA Group of Companies and/or any of its associated companies.
  • Premium -
  • 6% SST-
  • Stamp Duty-
  • Total

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