United Foreign Domestic Worker Insurance

United Foreign Domestic Worker Insurance

Statement pursuant to Section 25(5) of the Insurance Act, you are to disclose in this form, fully and faithfully, all the facts that you know or ought to know, otherwise this Policy issued hereunder may be void.

Your Particulars

Salutation*	Mr. Ms Mdm Dr
Full Name
Date Of Birth*
NRIC No*
Mailing Address


Contact Number*	(Office)
	(Home)
	(Mobile)
Email Address
Ocupation*
Name of Applicant’s Employer
Estimated Annual Income (S$)

Local Guarantor’s Particulars
(Local Guarantor is required if Applicant is a foreigner or with no income)

Salutation	Mr. Ms Mdm Dr
Full Name
Date Of Birth
NRIC No
Mailing Address


Contact Number	(Office)
	(Home)
	(Mobile)
Email Address
Ocupation
Name of Guarantor's Employer
Estimated Annual Income (S$)

Foreign Domestic Worker’s Particulars

Name*
Nationality*
Date Of Birth*
Passport No*
Work Permit Number*
SB Transmission Number*

Information on the Insurance to be taken up

Effective Date of cover

Type of Package (Total Premium inclusive of 7% GST)
Insurance benefits with Security Bond Insurance benefits without Security Bond

Plan Duration


Optional Cover
(This optional cover is only available for 26 months Plan)

Security Deposit Protection	Yes - S$53.50 (inclusive of 7% GST)
	No

Declaration and Agreement

	I understand submission of this electronic application does not constitute to an automatic confirmation of insurance cover.

	I am aware I will need to complete a Letter Of Indemnity if I am purchasing the Insurance Benefits with Security Bond.

	I hereby declare that the above statements and particulars are complete and correct and that no facts have been suppressed or mis-stated. I agree that this proposal shall form the basis of the contract between me and the Company.

	I am aware that I can seek advice from a qualified advisor before I sign this application form. Should I choose not to, I take sole responsibility to ensure that this product is appropriate to my financial needs and insurance objectives.

	I acknowledge and agree that UOI may collect, use, disclose, transfer my/our personal data for the Purposes stated in UOI's Privacy Notice which can be found at www.uoi.com.sg I further acknowledge by providing personal data relating to a third party (eg. Information of my dependent, spouse, children, parents and/or employees), I represent and warrant that the consent of that third party has been obtained for the collection, use and disclosure of the personal data for the Purposes stated in UOI�s Privacy Notice. I am aware that UOI may disclose personal data collected to its third party service providers or agents (including lawyers/ law firms), which may be sited outside of Singapore, for one or more of the above Purposes, as such third party service providers or agents, if engaged by UOI, would be processing the personal data for UOI for one or more of the above Purposes. This may include disclosure to industry association.



* Required fields