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Full name
Email
Phone Number
Gender
Marital Status
NRIC
Birthday

Your weight and height

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Height (cm)
Weight (kg)
Your BMI Index
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Your health details

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Do you suffer from stroke, diabetes, anaemia, hepatitis, heart or circulation disorder, kidney disease, tumour or cancerous growth, physical or mental disability or any other disorder?
Have your parents, brothers or sisters had (or died from) stroke, diabetes, multiple sclerosis, cancer, inherited disease, heart disease or kidney disease before the age of 50?
Have your application for any life, injury or illness insurance been declined, had special terms imposed or refused from being renewed before?
Do you have any existing chronic health conditions?
If yes, what condition do you have?

Your Residence Details

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Address
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Postcode
State
Country of Residence
Occupation
Industry

Your Residence Details

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