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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
~mtnrlniunuiarmou~iniuaiuuuulsuniumunnu~~u~?~~n~o n n u n a i l n n u ~ w O u ~ G ~ n ia ld~ i ia~udorn iu~ ia m3-u:
b0um?~<u~~n~u7uh:n'~url~~nlrlh~ij~riiin~~unn~n~(1i~i~~id~:n'~Pk mJou~nnpnu,uuri~w~ifil~~duimn ass
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
unrl?:hr(n-riu<um.ra~
1. taaWmrlnn$d 2. n i ~ n c r a n i c r h ~ a ~ n ~ ~ ' ~
pdani r
loo.wo- z,ow.ooo 1 0 0 . ~ 0 - 2.ooo.p~
~m.r i t~~~r ls : IYw~Yu riaynd.rmi, I urnnuin
468 32
t ~ ' m l r m ~ ~ m ? ~ ~ ( u ~ w a n r Q mo WIFIUII*
o i n d u d c ; ~ n f i b k A ~ n n 7 d 4 . a i o ~ u J c < u pi mum
o i n ~ d u ~ r m ~ u n s d ~ m a n i n L ~ ~ ~ ~ n n i n n i t u u i u o . ~ do;u~~mnirn'uu 1.m uln
n ~ o ' a n t d u d m i u ~ n n ~ ~ ~ u u ~ m'i17u 5.w a'a?urlxt7u 1.m mn
hu i t aui9nmnmlsoun~dmi'a~anu*i~d1:~nmIntl4in'a(a~. nm.) miiiu
" A #A " .. 8. ~ U ~ ~ ~ U ~ ~ U U W R Y J ( I U .............. I ilJuimu 2555 ...........................................................
Policy effective date
Does the applicant wish to have experience refund for Vlis policfl
slo4nl.i ba 'o tn i r
Yes No
10. ~nrauu%rornuiln~~~i~~ihuni~dxn'u<u Qualifications of eligible members
1. ~ o i d ? : ~ u ~ o r i i l u a u ~ b n m n ? & o ~ u n i H j n ~ ~ u ilk i l o i q m 4 i r 2&61 P iriiiu 2. ~ r n f l a u i ~ n d t o u ~ i u ~ i n n ~ u ~ n S u%n n?rlnu-uan* d rSu%a j i n ' m (nsum'~aan' 801-0002833)
C nrrnualK<uiud~u~un~o~u~~~ud~:n'udo~dor 3. h ~ l a u i b n d a ~ n r ~ ~ i l m u ' n i ~ i ~ ~ ~ ~ d x C u ~ : n i i ~ n'ornrsnlun'iwo~aidx~uynnun~ouuuu~~ui
u$dxnwuuaeiu~o~hluipnn*or 4. n ~ i a u ~ ~ n l ~ j n ~ ~ u i I r n ~ ~ i l u n ~ ~ u r n ~ i m i n u o a ~ i i l n u ~ u 6 i n i u ~ n l n w o ~ ~ u n ' 1 n o 1 o i d x ~ ~ h ~ ~ua:lm%
m i u { u n 7 o r y u d x i u 3 i ~ IO,OW uin d i ~ % n I ~ l ~ ~ ~ ~ ~ ~ 1 n n i ~ ~ ~ l h ~ ~ ~ : n ' u n 2 l ~ { ~ ~ 7 ~ ~ t ~ l ~ ~ d ~ ~ l l " ~
n r f l ~ f u ~ m i n q p d r m q Luaui3n.r:ln~un~iu(~n'1o~iiu~iu~u~uJrtnitnii lunrii '1u%a0inni~i~~~u
m i o ~ ~ u l l a o n i u n & n a i u { u m o ~ ~ ~ I il
b n ~ i u { u n ~ o r y u d x n ' u W a 1 o . o ~ uin h n % n ~ B i l u ~ i n ~ i n n 1 ~ ~ ~ u ~ 1 ~ u u ~ : l ( r ~ n i i u ~ u n ~ o r i m ~ u
d n " u n ~ ~ ~ i r u % a a i n ~ u ~ ~ n ? tauauibnr:~8"xm2lu(un7o~~iu~iua~~~d7:~un"~~un7&~~~im.rinn17
u ~ m ~ u n i ~ i i u i l ~ u n i u m a ' ~ n ~ i u ( ~ n ? o ~ n ~ I 9 5. aul~n6oi0~~~nl~ui~u7~1~~7&n'rfi4nl~1~~1~ado~~h~&nn$li?~nnd7:n'u~u
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
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