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TRANSCRIPT
PLUS STANDARD PLAN
.,J� � Lfl'llVl bU�:l-JrlL ......................... .
(Application No.)
DHIPAYA LIFE ASSURANCE
1 u rrit fl"J ! ii u rrini n"Ue-:i cf! e, 1tJ "J� nu Ktt n � ii 'ti q 'VJ'U'Ll�n'U ....................................... .
(Application For Group Life Insurance) FCL. ........................................ .
b'll1b'Via.i □ l�:JJ flli. □ �'1)111..:lU
c/ I .d • f1'J:JJ1i':irnf1�l.Jrn'IJV1 (Policy No.) .............................. -L., ................................ -H
e 9 ., d . 1'1.J':i'I.JnMrn'll'Vl (Certificate No.) ............................. .
.. ,, ., . THAI-JAPANESE DEVELOPMENT ASSOCIATION 1. 'IHllzV1':i..:lf1':il.J1i'J':il.J (Policyholder) ............................................................................... ................. . .. � a � 2. 'lfeJ�l.Jl'lff1 (Insured Person) ( ... ) 'Ulfl (Mr.) ( ... ) irn (Mrs.) ( ... ) 'W1..:im1 (Miss) ................................................. .
if� ., ... u � �if Fl E3 d • 1iPfT el1Q (Age) ..... � (Years) 1'\..! l\P1el'U lf1\P1 (Date ofBirth) ..................... 'Vlel� (Address) ............................................ .,={ ' o I
.................................................... ell'lf'VI (Occupation) ..................... \111U'l'l'U..:l(Position) ............................. .
3. 'IJ\11':i'l.h::;�71911 (I.D. card) ( ... ) th::;'lfl'lf'U (Nation I.D. card) (. .. ) -u'7':i1'lff11':i (Government I.D. card) ( ... ) t'U '7 (Other
PASSPORT .,; Jt�.;f-1--ffl:� Card) .............................................................. .lr.'l'IJ'Vl (Card No) .......................................................................... .
.,l ,,., • I i ., 4. 'lfellz':iHu':i::; fJ'lf'U (Name of Beneficiary)
.... ���JVfi .. E.f.� ............................ .
., ., ,I
i'111l.J�l.JVl'U1i (Relation) wctfJ;i
5. 1M��:Ui'l':i�l.J1'1ff1'1Jel.:J�lell'I.J':i::;f)lJ.flflf1zjl.JmeJf16U'eim1:u�eiitJif (Please give details as follows)
1:Y1'UU'U..:l % (Share)
%
5.1 n. 1:Y1'U�.:J (Height) ............... ��··················CJf.:U. (c.m.) J1'11'Uf1 (Weight) ............. ..1�� ............... f1.f1.(k.g.)
5.2 'IJ. 1m:::a::; s il ��7'\..!l.Jlif vi1'Wli'lfli¢l'i'1Jm1P11;1J '111eJl;'I.J'U1fl '111elli'lfli'mni11mi'm'W'Vlfl7'1.J1'1.'ll'i1ei'hi [email protected] rs%=:'tf:ft�M��!l.--::i tc. 1) *tda:;,( =f'-1-JJ J t;t ::,;5-c'5����kttc.L.c.tf-0 1) *9fJ\?(Over the past 5 years have you ever been injured, sickness, and taking advice from doctor?)
( ) li'lfJ (Yes) ( ) ili11'lfJ (No)
5.3 i'l. 1mh'lleirn1tJ1::;n'Wi1\11 l'i1eJ 1mi1'1JeJ�eJeJ1Q nrn1i1nf,J1::;n'Wi1\1111P1 '7 'Ue.:ivi1'Wli'lfl\Jf1U1'hl'Vl'I.J1:::n'Wifo tJfinrn l'i1eJ I I !JI 1
1iie'W nww,mt111 Y11el?i'e.:il'w:1.J1uvtJ1::;n'Wifo Y11e1tJifo'Uu'I.Jr.'l..:iU1J1J m1tJ1::;n'U.nf!Y11e '1li
(Have you ever been refused, deferred for acceptation, Insurance premium increased of face any changes in policy
conditions from this company of from any other company or not?)
( ) li'lfJ (Yes) ( ) '1li1i'lfJ (No)
[email protected]�*�HfJ\S�${��*��0)�®L ���, x'..ta:$��rn:a�ntc. iJ, 3jjj0)� -g-ptt� ��O)�•tt��n�L.c.��ij*9�?
