TMCare – Individual Hospital & Surgical
Proposal & Health Declaration Form
Under the Insurance Act, you must tell us all the facts that you know, or ought to know, about the risk that you
are proposing. If you do not tell us everything that is relevant or if you mislead us, we may refuse to pay a claimor part of it, or cancel the policy.

A. PARTICULARS OF APPLICANT
Full Name :NRIC No :Address :Race :
Sex / Marital Status :Date of Birth :Place of Birth:

Nationality :Occupation:

Height / Weight :Contact No. : (Off)

(Res)

(H/P)

B. PARTICULARS OF APPLICANT’S FAMILY MEMBERS TO BE INSUREDRelationship

NameSex

NRIC No.

Date of BirthHeightWeightSpouse
1st Child
2nd Child
3rd Child
Occupation of spouse:

C. INSURANCE COVER REQUIRED
Please select (✓) the insurance plan you wish o apply for:Plan A

Plan B

Plan C

Plan D

Period of Insurance : From

Plan E
to1.

2.

3.
4.
5.

6.
a.
b.
c.
d.

3rd Child

2nd Child

1st Child

SpouseHealth Statement

ApplicantPlease Indicate “YES” or “NO”

Have you or any of the family members to be insured ever had any life, accident,
hospitalisation or sickness insurance rejected or cancelled or issued on special
terms or declined on renewal?
Do you or any of the family members to be insured have life, accident,
hospitalisation or sickness insurance with this or any other company? (If “Yes”
please provide name of insurer, type of policy and policy reference below)
Are you or any of your family members to be insured currently under any
observation or receiving any treatment or medicine?
Do you or any of the family members to be insured have any physical defect,deformity, impairment of hearing or vision, or loss of hand, foot or vision?
Have you or any of the family members to be insured?
a) ever had a surgical operation?
b) ever been advised to have a surgical operation which has not yet been
performed?
Have you or any of the family members to be insured ever has or been told you had
or been treated for the following disorder or disease:
Chronic cough, spitting of blood, asthma, hay fever, pleurisy, tuberculosis or any
other disease of the respiratory system?
High or low blood pressure, heart disease, chest pain, heart attack, shortness ofbreath, palpitations or any heart disorder?
Apoplexy, paralysis, epilepsy, fits, dizziness, mental or nervous disorder?
Diabetes, sugar or blood in urine, kidney disorder, kidney colic or stone or hernia?
TMiS - Aug 2019

e.
f.
g.
h.
i.
j.
k.
7.

3rd Child

2nd Child

1st ChildSpouse

Health Statement

ApplicantPlease Indicate “YES” or “NO”

Arthritis, sciatica, rheumatism, back, spine, bone, joint, muscle or skin order?
Ulcer or disorder of the stomach, intestines, haemorrhoids or rectal disorder?
Gall bladder stone or liver disease or any type of hepatitis?
Cancer, tumour, or growth of any organ system, Thyroid disorder (such as Goitre), oranaemia?
Female reproductive system including lumps, but not limited to fibroids or cysts?
Sexually transmitted disease such as syphilis, gonorrhoea or herpes or non-specificurethritis?
Any illness or disease or injury not mentioned above?
Have you or any of the family members to be insured any intention of residing
outside Singapore for a period of more than 90 days?

If any of the answer to the above is “Yes”, give full particulars below, noting the question number.

Name and address of your regular doctor (if any)?

I hereby declare that:• the foregoing statement and particulars are true and complete and I have not withheld any information that may
influence the acceptance of this proposal, and I agree that this proposal and declaration shall be the basis of thecontract between Tokio Marine Insurance Singapore Ltd and I.
• the named family members to be insured are Singapore citizens or permanent residents or work permit holders oremployment pass holders working in Singapore.
I further understood and agreed that the proposal will be effective only if it has been accepted by the Company andthe applicable premium has been paid.
I hereby authorise any hospital, surgeon, medical practitioner, clinic or other medical or medically related facilities,
insurance company or other organisation or person to release to Tokio Marine Insurance Singapore Ltd, any suchinformation with respect to any illness and to provide earlier medical history concerning me or any named family
members to be insured.
I understand that all pre-existing conditions before the effective date of this policy are not covered.

Signature of Proposer / Date

Important Note for Proposer Who Did Not Receive Any Advice From An Adviser
I am aware that I can seek advice from a qualified adviser before I sign this application/proposal form. Should I
choose not to, I take sole responsibility to ensure that this product is appropriate to my financial needs andinsurance objectives.

Signature of Proposer / Date

For Official Use Only
Intermediary code
Total Premium (Before GST)
Family Discount
TMiS - Aug 2019IMPORTANT NOTICEPOLICY OWNERS’ PROTECTION SCHEME
This policy is protected under the Policy Owners’ Protection Scheme which is administered by the Singapore
Deposit Insurance Corporation (SDIC). Coverage for your policy is automatic and no further action is required
from you. For more information on the types of benefits that are covered under the scheme as well as the limitsof coverage, where applicable, please contact us or visit the General Insurance Association (GIA) or SDIC
websites (www.gia.org.sg or www.sdic.org.sg)
NOTICE FOR PERSONAL DATA PROTECTION POLICY
By signing this form:
1. I/We acknowledge and consent to TMiS collecting, using , processing and disclosing to third party service
providers and/or intermediaries, within or outside Singapore, my/our personal data for the purpose ofprocessing and servicing my/our policies/claims;
2. I/We declare and confirm that I/we have obtained the consent of the person(s) and/or nominee(s) named
herein, where applicable, and that he/she/they has/have authorized me/us to disclose their personal dataand to give consent on their behalf for the above collection, use, process and disclosure; and3. I/We

acknowledge

thedetailed

Privacy

PolicyStatement,

governingtheabove,postedat

www.tokiomarine.com.

Your Signature (Policy Holder) and Date
On behalf of person(s) to be insuredYour Full Name/Company NameYour NRIC/Passport No./Company Registration No.

TMiS - Aug 2019