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Integrated Shield Plan Application - IncomeShield

NTUC Income IncomeShield
Select Plan(*)
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Select Rider(*)
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Deluxe Care Rider - Reduce co-insurance from 10% to 5% and limit co-insurance to $3,000 p.a. on panel doctors. Covers annual deductible for panel doctors and limits annual deductible to $2,000 for non-panel doctors.
Classic Care Rider - Limit co-insurance to $3,000 p.a. on panel doctors.
 
About You
Occupation(*)
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Nature of Work(*)
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Name of Employer(*)
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Annual Income S$(*)
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Marital Status(*)
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Gender(*)
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Are you currently insured under any Integrated Shield Plan?(*)
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CPF account number (if different from NRIC/FIN)
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Upload Picture of NRIC - Front(*)
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Upload Picture of NRIC - Back(*)
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Your Medical History
Height (m)
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Weight (kg)
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Do you have any insurance policy that is pending or have you had any that had been refused, postponed or accepted at special terms by any insurer?(*)
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Have you made or are you intending to make any claim on any policy with any insurer?(*)
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Have you smoked cigarettes or cigars in the last 12 months?(*)
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Do you consume alcohol?(*)
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Have you been advised by a health care professional or a counsellor to reduce your alcohol intake, see a specialist, or to attend a support group because of alcohol intake?(*)
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You have answered Yes for a question above. Please enter Question Number and details here.
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Have you completed treatment or been discharged from medical follow-up?(*)
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Are you taking or have you ever taken addictive drugs or substances (for example, narcotics or glue sniffing)?(*)
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Do you have a doctor whom you consult for medical reasons other than common cold or flu?(*)
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In the last 5 years, have you had, or been advised or referred to undergo any medical tests or investigations?(*)
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For example, blood test, urine test, X-ray, ECG, ultrasound, imaging scan, biopsy, mammogram, Pap smear, prostate check.

Have you ever taken a HIV test, received any medical advice, counselling or treatment in connection with sexually transmitted disease, AIDS, AIDS-related complex or any other AIDS-related conditions?(*)
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Have you ever experienced symptoms or received medical advice or referral or had treatment for any of the following conditions?(*)
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a. Eyes, Ear, Nose & Throat

b. Mental Disorders

c. Nervous and Neurological System

d. Respiratory System

e. Cardiovascular and Circulatory System

f. Liver and Gall bladder

g. Gastro-Intestinal System

h. Renal and Genito-urinary system

i. Blood disorders and autoimmune system

j. Endocrine

k. Musculoskeletal system

l. Growth (cancer, cysts etc)

m. Skin (Eczema, Keloid etc)

n. Excessive weight loss

o. Physical or developmental impairments

p. Any other illness, disorders, symptoms, operation, treatment, physical disability, accident or injury not mentioned above.

Are you now pregnant?(*)
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Have there been any complications relating to this or previous pregnancies?(*)
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You have answered Yes for a question above. Please enter Question Number and details here.
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Contact Details
Email(*)
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Handphone No.(*)
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Where did you hear about us?
Where did you hear about us?

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