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Fax:
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Enter age (Father - Mother):
Enter age (Spouse):
Enter age (Child 1):
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Choose Class:
1st Class 2nd Class
Monthly Payment:
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Monthly Payment Quarterly Payment Half Yearly Yearly Payment
1st Class
In
Yearly Cover
25,000
Deductable
10%
Max./Stay
5,000
Out
1,000
2nd Class
15,000
3,000
750