Client Details

Branch of Request*
CSR*
CSR*
CSR*
CSR*
CSR*
Policy Type*
Policy No. (If unknown please tick box on the side)*
Policy No. (If unknown please tick box on the side)*
Policy No. (If unknown please tick box on the side)*
Policy No. (If unknown please tick box on the side)*
Policy No. (If unknown please tick box on the side)*
Policy No. (If unknown please tick box on the side)*
Golden Sunset
Salutation
First Name*
Middle Name
Last Name*
Please update the information below
Salutation
First Name*
Middle Name
Last Name*
Current Home Address*
Town/City*
Country*
Mobile No.*
Home No.
Work No.
Is your Mobile # your Whatsapp #*
- Yes
- No
- I don't have Whatsapp
Mobile No.
Enter the number you can be contacted on Whatsapp
Email*
Pep Status:*
- Yes
- No
Politically Exposed Person
Method of Information Collected*
In House - Email / Telephone
For your convenience, all statements and communications from our Company, in the future, may be sent to you via email or Whatsapp messages. If you do not wish to receive such forms of communications, please inform us by sending an email to [email protected]
General Comments
Signature of Policyholder
- Type-in Signature
- Digital Signature
In House Signature*
Signature*
Date*
Date Format: DD slash MM slash YYYY

Please update the information below