Income SpecialCare Insurance

PARTICULARS OF PROPOSER Fields marked with (^) are compulsory

^Name:	(As shown in NRIC)
^NRIC:	(eg: S1234567A)
^Date of Birth:	(dd-mm-yyyy)
^Gender:	MaleFemale
^Nationality:
^Singapore PR Nationality:
^Country of Residence:
^Address Type:	LocalForeign
^Dwelling Type:	HDBOthers
^Postal Code:	Unit No:

^Home Address:
^Contact No.:	(Home) (Office) (Mobile)
Please provide at least one contact no.
Email:
^Please note that personal particulars keyed in this form will not overwrite any existing records that you have with Income. For changes to be made to your particulars, please log into me@income, 'Manage My Particulars' section.

PARTICULARS OF LIFE ASSURED
^Name:
^NRIC:
^Nationality:
^Singapore PR Nationality:
^Country of Residence:
^Gender:	MaleFemale
^Date of Birth:	(dd-mm-yyyy)
^Relationship to Proposer:
Occupation:
Name of Current Education Institution/Employer:

DETAILS OF INSURANCE REQUIRED

^Effective Date:	(dd-mm-yyyy)
^Duration of Insurance Coverage:	One Year

BASIC COVERAGE

^	Plan 1	Plan 2
Accidental death and permanent disability of policyholder	$30,000 in each insured person's lifetime	$60,000 in each insured person's lifetime

Waiver of premium due to accidental death of policyholder	Amount of premium, up to 5 years in each insured person's lifetime	Amount of premium, up to 5 years in each insured person's lifetime

Final expenses	$5,000 in each insured person's lifetime	$5,000 in each insured person's lifetime

Permanent disability of insured person	$30,000 per policy year	$60,000 per policy year

Outpatient expenses due to accident	$2,000 per policy year (up to $200 for each accident)	$3,000 per policy year (up to $300 for each accident)

Hospitalisation expenses due to accident	$5,000 per policy year (up to $1,200 for each accident)	$7,500 per policy year (up to $2,500 for each accident)

Medical expenses due to infectious disease	$1,000 per incident	$2,000 per incident

Daily hospital income	$50/day (up to 60 days for each accident)	$75/day (up to 60 days for each accident)

Ambulance fee	$500 per policy year (up to $100 for each accident)	$500 per policy year (up to $100 for each accident)

Mobility aids	$500 per policy year	$1,000 per policy year

Physiotherapy and psychiatric therapy	$1,000 per policy year (up to $100 per visit for each accident)	$2,000 per policy year (up to $200 per visit for each accident)

Personal liability	$5,000 per policy year	$5,000 per policy year

Modifying your home	$3,000 in each insured person’s lifetime	$6,000 in each insured person’s lifetime

Training your caregiver	As charged (once for each accident)	As charged (once for each accident)

Lifetime limit	$100,000	$150,000

OTHER PARTICULARS


^1.	Do you have any mobility problem where you require walking stick, wheelchair, walker or crutches for daily movements and activities? If yes please give details of your mobility condition, how long have you been using the mobility aid? Are you under any medication to treat your mobility problem or do you need any medical follow up? NoYes
^2.	Have the insured visited a medical clinic or hospital because of an injury in the past 12 months? If 'yes', how many times have the insured visited a clinic or hospital due to an injury? Please give details of each visit and if the insured need any medical follow up? NoYes
^3.	Is you the insured suffering from any of the following conditions?: a. Epilepsy b. Total blindness and/or deafness c. Diabetes requiring insulin treatment if 'yes', - when was the insured diagnosed with the condition? - Is the insured currently under any medication to treat his/her condition? - Does the insured need any medical follow-up? How frequent? NoYes

Rep Name:		Rep Code:	(eg. 1234567890)
Introducer Code:	S (e.g 0123456789) (Applicable to DB Staff Only)
Campaign Code:

SpecialCare (Autism) Insurance