Employee Benefits Insurance

GENERAL INFORMATION
Period of Insurance	A value is required.* (ddmmyyyy) to A value is required.* (ddmmyyyy)
Business Name	A value is required.*
Nature of Business	A value is required.*
Is your company currently insured?	Please select an item.* Current Insurer Name Current Type of Policy Current Period of insurance from (ddmmyyyy) to (ddmmyyyy)
Total No. of Employees	A value is required.*
Total No. of Employees to be insured	A value is required.*
Person to Contact	A value is required.*
Contact No.	A value is required.* (Mobile) (Office) (Fax)
Email

Are there any members currently in hospital or requires frequent admission (e.g. hospital admission more than 2 times per year) to hospital?

Please select an item.*

Has any member suffered or is suffering from any serious condition such as cancer, organ failure, heart disease, stroke, liver disorder, arthritis or any other disorder that causes progressive irreversible functional or physical disability?

Please select an item.*

Is there any member based outside Singapore?

Please select an item.*

Are there any limitations or exclusions imposed on the coverage on any members?

Please select an item.*

Is there any member engaged in hazardous occupation? (eg. welder, diver, sandblaster, offshore workers etc.)

Please select an item.*

To the best of your knowledge, is there any member engaged in hazardous sports? (eg. scuba diving, motor racing, bungee jumping etc.)

Please select an item.*

Please tick (✔) the employee benefits you need

Group Term Life (GTL)

Group Personal Accident (GPA)

Group Critical Illness (GCI)

Group Disability Income (GDI)

Group Hospital & Surgical (GHS) / Group Major Medical

Group Outpatient (GOP) / Dental

Maternity

Referrer (if any)
Referrer Name
Referrer Contact No.
Referrer Email

#	no. of members	Age	Reason of hospitalisation / Nature of illness	Total Sum Insured / Plan
1
2
3
4

#	no. of members	Age	Reason of hospitalisation / Nature of illness	Total Sum Insured / Plan
1
2
3
4

#	No. of members	Age	Country based in	Total Sum Insured / Plan
1
2
3
4

#	No. of members	Age	Limitations / Exclusions	Total Sum Insured / Plan
1
2
3
4

#	No. of members	Age	Nature of work	Total Sum Insured / Plan
1
2
3
4

#	No. of members	Age	Type of sports	Total Sum Insured / Plan
1
2
3
4

BAsis of coverage
#	Category of Employees / Occupation	Basis of Coverage Sum Insured	# of Employees
1
2
3
4

Details of Employees
Age Band (Age Next Birthday)	# of Employees		Total Sum Insured (S$)
Age Band (Age Next Birthday)	Male	Female	Male	Female
16-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
Total

paid claims experience for past 3 years
period of coverage From	period of coverage to	# of Claim	Claim Amount S$
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)

outstanding claims experience for past 3 years
period of coverage From	period of coverage to	# of Claim	Claim Amount S$
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)

Is GDI participation Compulsory or Voluntary?
If currently insured, please attach a copy of the definition of Disability.
What is the waiting period required?	months (3 or 6 months or others)
What the benefit duration required?	years (up to retirement age 60 or 62, or 65)
What is the escalation benefit required?
Please provide Current Non-Medical Limit (if applicable)	S$ up to age
Any requirement for partial disability benefits?

Basis of Coverage
Category of Employees / Occupation	Monthly Salary (S$)		Basis of Coverage i.e. % (e.g. 50%) of monthly salary
Category of Employees / Occupation	Highest *	Lowest *	Basis of Coverage i.e. % (e.g. 50%) of monthly salary
1
2
3
4
* Applicable to the category of employees as stated. Monthly salary will be basic pay + fixed bonus if any. It excludes variable bonus, commissions, etc.

Claims Experience for the past 3 years
Date of Disability	Cause of Disability / Nature of Illness	Claims Amount (S$)
Date of Disability	Cause of Disability / Nature of Illness	Paid	Outstanding
(ddmmyyyy)
(ddmmyyyy)
(ddmmyyyy)

Is GHS participation Compulsory or Voluntary?
Is GMM participation Compulsory or Voluntary?

Basis of Coverage
Category of Employees / Occupation	Room & Board Benefit Plan (S$)	Currently with TMIS	Proposal with TMIS Yes / No
1
2
3
4
Important Note: (1) Dependants can be covered under Group Hospital & Surgical Plan. Their cover should be the same as the employee’s cover. (2) Please provide the Deductible /Co-insurance for respective employee category or occupation, if applicable.

Age Profile of Employees
Age Band (Age Next Birthday)	# of Employees
Age Band (Age Next Birthday)	Male	Female
16-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
Total

Details of Insured members For GHS
Plan Type	# of Employees (Singaporeans & SPRs*)				# of Employees (Foreigners* only)
Plan Type	Plan 1	Plan 2	Plan 3	Plan 4	Plan 1	Plan 2	Plan 3	Plan 4
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family

Details of Insured members for gMM (if different from GHS)
Plan Type	# of Employees (Singaporeans & SPRs*)				# of Employees (Foreigners* only)
Plan Type	Plan 1	Plan 2	Plan 3	Plan 4	Plan 1	Plan 2	Plan 3	Plan 4
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
* refers to Singapore Permanent Residents ** refers to all foreigners holding Employment Pass, S Pass and Work Permit, working in Singapore

Claims Experience for the past 3 years
Date of Coverage		# of Insured as of now	Claims Amount (S$)
From	To	# of Insured as of now	Paid	Outstanding
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)

Is Group Outpatient participation Compulsory or Voluntary?
Is Dental participation Compulsory or Voluntary?

Category of Employees to be insured (please tick as appropriate)
Category of Employees	Clinical GP	Specialist	Diag X-Ray / Lab Tests	Dental
1
2
3
Dependant (where applicable)
# of Headcount

paid claims experience for the past 3 years
Period of Coverage		# of Insured as of today	Clinical*		Specialist *		Diagnostic XRay / Lab Tests*		Dental*
From	To	# of Insured as of today	# of Visits	Amount (S$)	# of Visits	Amount (S$)	# of Visits	Amount (S$)	# of Visits	Amount (S$)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
* inclusive of visits to non-panel clinics

outstanding claims Experience for the past 3 years
Period of Coverage		# of Insured as of today	Clinical*		Specialist *		Diagnostic XRay / Lab Tests*		Dental*
From	To	# of Insured as of today	# of Visits	Amount (S$)	# of Visits	Amount (S$)	# of Visits	Amount (S$)	# of Visits	Amount (S$)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
* inclusive of visits to non-panel clinics

Kindly attach a copy of the Schedule of Benefits if the benefits are on insured basis. If currently self-insured, kindly provide the following details: Please indicate “Unlimited” if there is no cap and “NA” if it is not applicable.
Benefits	Maximum Limit per Visit (S$)		Maximum Limit per Policy Year (S$)		Co-Payment (S$) / Co-Insurance (%)
Benefits	Clinic on Company’s panel	Non-panel Clinic	Clinic on Company’s panel	Non-panel Clinic	Clinic on Company’s panel	Non-panel Clinic
Clinical GP
Specialist
Diagnostic X-Ray / Lab Tests
Dental
Others

Claims Experience for the past 3 years
Date of Coverage		# of Insured as of now	Claims Amount (S$)
From	To	# of Insured as of now	Paid	Outstanding
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)
(ddmmyyyy)	(ddmmyyyy)

Benefits	Maximum Limit per Policy Year (S$)	Deductible / Co-insurance (S$)
Normal Delivery
Caesarian Delivery
Others