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~~6iaernid~rn 'Pr i l3aniardi~~~pl 'Wan~aras~i q 91

Gmup Application Fcim for Policyholder

6. s r a n i ~ ~ ~ t G u ~ ~ : ~ u m nu3 n u 6 tAou n u 3 t l s u n u ~ i i o u

Mode of premium payment Mnual Semi-annual QuarterIy Monthly

.I t~unnmmai. ........................ ~ o ~ i u n m i u w h i 7 ................ rtu%& G"TL?BPUU~? ........... ~ u o q q i a .... 550~0041~0 .... Policy No AgenVBmker License No.

di1~ausul l~r innuarr7 lnuni~~duuad~1Inunnouqr i ior ln~ur iu

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I. ~o{uatoid-lmi'-u (Eiqnna) aun'1doaun~dm~n~uulnl.r:rna~nu8.iri~ ............................. Applicant (Company name)

w " .......................................... 2. h ~ n ~ i u m u d .............. 99 ui 3 ................. roo.. ......................... nnu ................... u e u ~ a ~ w m c e address No. Soi - Road

" - u u ~ ......... + u o u t u ........................... mm .................. n a n d ...................... nil~ln~ ...... n y t n n u ~ i n a 7 . District Amphor Province . # " ,

~ ~ a ~ d n t r n u ........ 10002 ............... : .................. Tns~wn ....... W104-4344 .......................................... Postcode Telephone No.

- 4 3. a'nuw pinil ................ m n m l o a n m m ..............................................................................................................

Type of buiness

4. aoutunrnnlcnirr iu d Ginuu%inIutnio/mai n u u i l i n l u t n i a ~ m a i Ldircy Insurance range Excluding amiiated companieshranches Including aRliated companieslbranches

Please Specify

7. @~~aid1:~uSumnu~d~:Tun"u l?~uui~dcnirn'uun'u~um~oIri Has the applicant had iwurance vim otner insurance companies before?

a t n u r i i d 1 : ~ r n ' u ~ u ~ ~ n . . . ... nlo lnu-uant i i ~ ~ s z i i w g i m 61% ..... i u A a e n m r m J ................. Yes, with Policy expiry date.

b t n u NO

%auilinlcompany name m o l u d ~ ~ ~ d d r e s s _I rinr%~fi i l iType of Busineu

5. detnnun~miu funsor / .Jiu~u~~u~oid.znirn'uun"u Type of cowrage / Sum insured

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pdani r

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468 32

t ~ ' m l r m ~ ~ m ? ~ ~ ( u ~ w a n r Q mo WIFIUII*

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" A #A " .. 8. ~ U ~ ~ ~ U ~ ~ U U W R Y J ( I U .............. I ilJuimu 2555 ...........................................................

Policy effective date

Does the applicant wish to have experience refund for Vlis policfl

slo4nl.i ba 'o tn i r

Yes No

10. ~nrauu%rornuiln~~~i~~ihuni~dxn'u<u Qualifications of eligible members

1. ~ o i d ? : ~ u ~ o r i i l u a u ~ b n m n ? & o ~ u n i H j n ~ ~ u ilk i l o i q m 4 i r 2&61 P iriiiu 2. ~ r n f l a u i ~ n d t o u ~ i u ~ i n n ~ u ~ n S u%n n?rlnu-uan* d rSu%a j i n ' m (nsum'~aan' 801-0002833)

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m i o ~ ~ u l l a o n i u n & n a i u { u m o ~ ~ ~ I il

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11. d o u I n ~ ~ n u ~ A u ~ ~ u Special conditions

imounln;u<ma%na;1 lisuunn.&~n'n'mue&~~-ek~ndmn u . r h s o u l J ~ l & d G a m ~ ~ d ~ n ~ 1 i ~ ~ 1 ~ c n ~ u n d v ~ ~ l y ~

rn~iu,m<yniuli The applicanl celtifies Ulat the above $ta(emenl is Vue and gives mnsentlo Uls Company to

Underwriting pwose.

l o fi4. dddr .................................................................... iunii o w 3

a tu iu m ( u i u i l uc i n i uni id~7u: )

Date ditinlia!Position dxmunnu rnm i~ i r un i . r

<nolmdx~ununu/Aqplicant

( u i u u y n y ~ ~ n ' n f