FWMI - Proposal Form
Uploaded by
SivakumarFWMI - Proposal Form
Uploaded by
SivakumarPROPOSAL FORM
FOREIGN WORKER MEDICAL INSURANCE
Intermediary Code :
Z0002732
Intermediary Name :
LIM TZE WYNN
IMPORTANT
Statement pursuant to Section 23(5) of the Insurance Act 1966, you are to disclose in this Proposal Form fully and
faithfully all facts which you know or ought to know, otherwise you may receive nothing from the policy.
Completing the Proposal Form
If you have insufficient space to complete any of your answers, please attach a separate signed and dated sheet.
1. PROPOSER’S PARTICULARS
Company Name: ATLAS M&E SERVICES PTE. LTD.
Company Address: 1 SOON LEE STREET, #05-60, PIONEER CENTRE, SINGAPORE 627605
Company Registration No. 202223999E Year of Incorporation: 2022
Nature of Business: ELECTRICAL WORKS (43210)
Name of Contact Person: SARA
Contact Number: 8134 3200 Email: [email protected]
2. DETAILS OF INSURANCE
Period of Insurance: From: 13-01-2025 To: 12-01-2026 (both dates inclusive)
For office use only:
Plan Type (please tick): Plan 60 Plan100 Annual Premium per employee: S$
Optional Rider per employee: S$
Optional Rider (please tick): Yes No
Total Premium per employee: S$
(Waiver of Co-payment of 25%)
Total No. of employees:
Total Premium payable (inclusive of GST): S$
3. DETAILS OF INSURED EMPLOYEES
Passport No. /
S/N Name of Employee Date of Birth Gender Nationality
Work Permit No.
1
HFW (1 June 2023.v1) 1|Page
4. CLAIMS EXPERIENCE FOR THE PAST 3 YEARS NONE
Period of Coverage (DD/MM/YYYY) Paid Claims Outstanding Claims
From To No. of Claims Amount (S$) No. of Claims Amount (S$)
The Insurer reserves the rights to request for more information.
5. PRIOR INSURANCE
(a) Has the Proposer taken up a similar policy previously? Yes No
(b) Has any Insurer in respect of such insurance
i) Decline your proposal? Yes No
ii) Cancelled or refused to renew your policy? Yes No
If the answer is ‘Yes’ to any of the above questions, please provide details:
6. DECLARATION AND SIGNATURE
We declare that all the Insured Employees as declared are in good health and free from any physical defects or infirmity.
The undersigned authorized officer(s) of the Proposer further declare that to the best of their knowledge and belief the
statements set forth herein and all attachments are true and complete and immediate notice will be given should any of the
above information alter between the date of this proposal and the proposed date of inception of any in surance. Although
the signing of the Proposal Form does not bind the undersigned on behalf of the Proposer to effect insurance, the undersigned
agree that this proposal form and all attachments herein shall be the basis of and will be incorporated in the Policy should one
be issued.
Policy Application, Service and Administration
The Policyholder hereby confirms and represents to the Company, its related corporations (collectively, the “Companies”), as well as their
respective representatives and agents (“Representatives”) that each Insured Person has agreed and consented to the disclosure of
his personal data to the Companies and their Representatives, and further, that for the Companies and their Representatives’ collection,
use and/or disclosure of the personal data of the Insured Members, and disclosing such personal data to the Companies’ authorised service
providers and relevant third parties for purposes reasonable required by the Companies to provide the insurance coverage under this Policy.
In respect of the Insured Persons who are subsequently enrolled into this Policy, the Policyholder further undertakes that it shall ensure and
procure that each of such Insured Persons has provided such agreement and consent in relation to his/her personal data for such purposes.
These purposes are set out in the Company’s Privacy Statement, which is accessible at https://www.greateasternlife.com/sg/en/privacy-and-
security-policy.html and which the Policyholder hereby confirms that both the Policyholder and the Insured Persons have read and
understood.
PANNEER SELVAM SIVAKUMAR
Name of Authorised Officer Signature
DIRECTOR 11-01-2025
Designation Date
NOTE: This insurance will not be in force until the Company has accepted the proposal.
HFW (1 June 2023)
2|Page
