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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 : *

Country : *
Postal : *
Contact Person :
Phone No. : *
Fax No. :

Worker's Particulars

Name of Worker : *
Date of Birth : *	(dd-mm-yyyy)
Nationality : *
Passport No. : *
Work/Spass Permit No. : *
Effective date : *	(dd-mm-yyyy) (For renewal case, Effective date should be 1 day after expiry date)
Occupation : *

Plan Selection

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

S$15,000 Foreign worker medical insurance - Premium : $85.60 (inc. GST)

S$15,000 Foreign worker medical insurance with extension to cover Covid-19 treatment within 14 days upon arrival to Singapore - Premium : $130.54 (inc. GST)

S$15,000 Foreign worker medical insurance with extension to cover Covid-19 treatment within 21 days upon arrival to Singapore - Premium : $149.80 (inc. GST)

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

Authorized Agent of:

Authorized Agent of:

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