Maid insurance

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Applicant Name

Gender

Phone

(###)

###

####

Has your domestic helper ever been declined by insurance company to accept or renew or required special terms and/ or additional premium for any of the domestic helper insurance policy? If “yes”, please give full details.

Would your domestic helper require any foreseeable need for treatment or for consulting any doctor or has ever been confined in a hospital for surgery or medical treatment in the last three years? If “yes”, please give full details of such surgery or medical treatment and the related costs.

Details of Domestic Helper

Does the overseas domestic helper require to perform driving duties

Domestic Helper Name

First Name

Last Name

Gender

Date of birth

YYYY

Country of Residence

Policy commence date

YYYY

Additional Info