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EMployee basic Information

(*All fields are mandatory)

Sub Office / Entity

Last Name / Surname

Gender

Female

Male

date of birth

Marital Status

Email Address * To Provide Later

Nationality

Postal Code * To Provide Later

Residential Address *

Prolonged Illness Leave

First Name

Date of Employment

NRIC/PASSPORT No.

Employee Number

Mobile

Country of Residence

Bank Account No. * To Provide Later

Branch Code

Swift Code

Job Designation / Occupation

Salary (For Life Benefit Type -> Multiple of Salary) * To Provide Later

Effective Date

EMPLOYEE’S COVERAGE

Policy Number :

Effective Date

Plan

Sum Assured

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