Mobile Insurance Application Form
NTUC X 20%more
* Required
Last Name/Surname
*
First Name
*
NRIC/FIN
*
Date of Birth
*
Applicants must be at least 21 years old
Mobile Number
*
Address 1
*
Block Number and Street Number (e.g. 8 Short Street)
Address 2
*
Unit Number, if not applicable please enter -
Postal Code
*
Email
*
Brand of Mobile Phone
*
Apple
ASUS
HTC
Huawei
LG
Oppo
Samsung
Sony
Google
Xiaomi
Motorola
Others
Model of Mobile Phone
*
If previous submitted choice was 'Others', please enter brand and model in this section
IMEI Number
*
To find your mobile phone IMEI number, please dial *#06#
Is the mobile purchased within a year?
*
Mobile phone must be purchased for less than twelve (12) months
Yes
No
Did you directly purchase the mobile phone from Singapore's mobile phone manufacturers/distributors' retail store
*
e.g. Singtel, Starhub, M1, Apple, Samsung
Yes
No
Which manufacturers/distributors did you purchase from?
*
Singtel
M1
Starhub
Circles.
Apple
Samsung
Other:
When does your current mobile phone contracts ends?
*
Within 6 Months
Within 12 Months
Within 24 Months
Not on any contract
By Submitting the form, you agree to the Terms and Conditions listed below the form.