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Integrated Shield Plan Application - MyShield

Aviva MyShield
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Select Rider(*)
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A-II Rider - Reduce co-insurance from 10% to 5% and limit co-insurance to $3,000 p.a. on panel doctors. Extend post-hospital cover to 365 days.
C-II Rider - Reduce co-insurance from 10% to 5% and limit co-insurance to $3,000 p.a. on panel doctors. Covers annual deductible. Extend post-hospital cover to 365 days.
 
About You
Occupation(*)
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Nature of Work(*)
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Name of Employer(*)
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Annual Income S$(*)
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Monthly Income S$(*)
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Monthly Expenses 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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Are you a smoker?(*)
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Number of stick(s) per day(*)
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Have you had an application of a Life, Critical Illness, Health, Accident, Disability policy deferred, declined or required to pay Additional Premiums for MediShield Life? (*)
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In the last 5 years, have you had any medical test(s) with abnormal results, such as X-ray, ultrasound, imaging scan, biopsy, electrocardiogram (ECG), blood or urine test, prostate check, pap smear or mammogram? (*)
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Are you currently experiencing symptoms or considering seeking medical advice or treatment for your health other than minor illnesses such as cold and flu?(*)
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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) Heart attack, chest pain or discomfort, irregular heart beat, heart valve disorder, heart murmur, palpitations or any other blood vessel or heart disease or disorder?

b) High blood pressure or high cholesterol?

c) Cancer, or malignant tumour/growth/lump/nodule/polyp/ cyst of any kind including cancer screening tests that were not normal?

d) Benign tumour/growth/lump/nodule/polyp/cyst?

e) Diabetes, elevated or raised blood sugar, thyroid disorders or any other endocrine disease or disorder?

f) Asthma, bronchitis, pneumonia, tuberculosis, emphysema or any other breathing or lung disease or disorder?

g) Depression, anxiety, stress or any other mental or nervous disorder?

h) Drug or alcohol addiction or abuse?

i) Arthritis, gout or any other disorder, pain or injury to the muscles, bones, tendons, limbs, joints, spine (back or neck)?

j) Stroke, epilepsy, fits, paralysis or weakness of limb, head injury or any other neurological disease or disorder?

k) Crohn’s disease, ulcerative colitis, stomach or duodenal ulcers, or any other bowel, stomach or intestinal disease or disorder?

l) Hepatitis B or C, fatty liver, jaundice, abnormal or elevated liver function, gallstones or any other liver or gallbladder disease or disorder?

m) AIDs, HIV or sexually transmitted disease?

n) Anaemia, thalassaemia, haemophilia or any other blood disease or disorder?

o) Kidney stones, kidney infection, urine abnormalities or any other kidney, bladder, prostate or gynaecological disease or disorder?

p) Eye, ear, nose or throat disease or disorder (excluding sight problems corrected by prescription lenses)?

q) Any other illness, disorder, operation, physical disability, injury or hospitalisation not mentioned above?

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Contact Details
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Where did you hear about us?
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