3113-1331
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Prefix
First Name:
Last Name:
HKID or Passport:
Email:
Contact No:
Date of Birth:
Occupation:
Name of Golf Club (if any):
Address:
Start Date:
Do you suffer from any disabilities or infirmities?
Have any insurers ever cancelled, declined or refused to renew any policies held by you?
Have you had a "hole-in-one" during the past 3 years? If yes, state the golf course(s) and date(s) below.
Have you sustained any loss, damage, liability or accident indemnified under any golf insurance cover during the past three years?
If you have answered "Yes" to any of the above, please give more details:
Premium:
Payment Method: