| Agent Name |
|
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| Agent No. |
|
| Your Personal Details (*denotes compulsory field) |
| *Title |
Other
|
| *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 |
|
| In which currency would you like to have your plan issued? |
USD
EUR
GBP
Other
|
| You may insure up to 75% of your current annual salary. The maximum you can insure under the Global Income plan is GBP 90,000 or USD 144,000 or EUR 144,000. |
| Amount of benefit required |
|
| The deferment period you would require before the income benefit start |
3 Months
6 Months |
| What age would you like cover until? |
60
65 |
| Comments |
|
| How do you know BHFS? |
Bali Advertiser
Jakarta Post
Web Search
www.expat.or.id
Agent
Other
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|
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