Plan Type     How did you hear about us? -- Please select -- YAHOO GOOGLE EXISTING CLIENT REFERRED BY CLIENT REFERRED BY FRIEND REFERRED BY FALCON STAFF OTHER Insured Only Insured & Spouse Insured & Child Insured & Family Insured Combination Payment Mode (By Credit Card) SilverGold Annual PaymentMonthly Payment * * * Info on Plan Type If your answer for the question above is 'Other', please provide details:

*                   Remarks: 1. The insured persons must be aged between 91 days to 65 years old (renewable up to 75 years old) 2. Child(ren) refer(s) to insured's unmarried child aged between 91 days to 17 years old or full-time student aged 22 or below 3. Child(ren) (below aged 17 years) must insure with parents