| Agent Name |
|
|
| Agent No. |
|
Your Personal Details (*denotes compulsory field) |
| *Title |
|
| *Surname |
|
| *First Name |
|
| *Date of Birth |
|
| *Nationality |
|
| *Location |
*If you are in Indonesia please denotes compulsory field
Outside of Jakarta
|
| *Occupation |
|
| *Smoker |
Yes
No |
|
Your Contact Details (*denotes compulsory field)
Please provide at least one contact telephone number so that we may speak to you purely for clarification purposes if necessary. |
| *Your E-mail |
|
| Phone (Office) |
|
| Phone (Home) |
|
| Phone (Mobile) |
|
| Fax |
|
| Second life to be insured |
| Surname |
|
| First Name |
|
| Relationship to you |
|
| Date of Birth |
|
| Marital
Status
|
|
| Nationality |
|
| Location |
|
| Smoker |
Yes
No |
| In which currency would you like to have your plan issued? |
USD
EUR
GBP
Other
|
| Amount of benefit required |
|
| Life assured basis |
Single Life
Joint Life First Claim
Joint Life Second Claim |
| Benefit type |
Life Cover
Life and Critical Illness Cover |
| Premium frequency |
Monthly
Quarterly
Half/Yearly
Yearly
|
| Comments |
|
| How do you know BHFS? |
Bali Advertiser
Jakarta Post
Web Search
www.expat.or.id
Agent
Other
|
|
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