Underwritten By:

Liberty Insurance Pte Ltd Registration no. 19900279D 51 Club Street #03-00 Liberty House Singapore 0 9!2" #el$ % 5& 221 " 11 'a($ % 5& 22 33 0 )ttp$**+++.libertyinsuran,e.,o-.sg

Arranged By:
Inspro Insurance Brokers Pte Ltd .o. 1 C)angi Sout) Lane/ #03-01 0,,or1 'a-ous Distri,t Centre/ Singapore !" 070. #el$ % 5& 53" 3""3 'a($ % 5& 5! 0" * 5! 21

0ebsite: +++.inspro.,o-.sg 23. $o 4;;76G47;H

Domestic Maid Application Form

The insurance Act: You are to disclose in the proposal form fully and faithfully all the facts which you know or ought to know in respect of the risk that is being proposed; otherwise the policy issued hereunder may be void A. PROPOSERS PARTICULARS B. MAIDS PARTICULARS
$ame of Maid The !roposer /Date of -irth %DD)MM)YYYY' Address Marital "tatus Telephone $o %&' %()!' %*' $ationality Annual +ncome %".' Age "e# ) $ationality 1ffective Date %dd)mm)yyyy' From ) 0ork !ermit $o !assport $o

$&+, $o *ccupation

"- Transmission $o

$ame of ,ompany

D.

26 Mon !" 1# Mon !" %!lease Tick' REIM$URSEMENT OF INDEMNIT% PAID TO

) ) for

INSURER& %'" / No %!lease Tick'

, CHOICE OF INSURANCE COVERAGE (!lease see details

overleaf':

%For details of coverage2 please see overleaf '

Plan 1 / Plan 2 / Plan 3 %!lease Tick'

To : Dear "irs2

LETTER OF INDEMNIT%

L()'* + In",*an-' P ' L ./ 34 ,lub "treet 5678662 9iberty (ouse2 "ingapore 6:;<=>

&1: ,*?$T1&8+$D1M$+TY F*& 91TT1& *F @?A&A$T11 $* AAAAAAAAAAAAAAAAAAAAAA +n consideration of L()'* + In",*an-' P ' L . %Bthe insurerC' agreeing at my)our reDuest to issue a 9etter of @uarantee %Bthe @uaranteeC' in favour of Ministry of Manpower %BM*MC' guaranteeing the payment on demand of any sum or sums not e#ceeding in total "ingapore Dollars Five Thousand %".32666' in lieu of the cash deposit of "ingapore Dollars Five Thousand %".32666' that the employer would otherwise have to provide as security under the "ecurity bond e#ecuted by the employer in favour of M*M2 +)we hereby Eointly and severally irrevocably and unconditionally agree and undertake for myself)ourselves and my)our heirs e#ecutors administrators assigns and successors that 4 = As a continuing obligation +)0e shall indemnify and keep indemnified the insurer from and against all claims2 demand2 payment2 actions2 suits2 proceedings2 losses2 e#penses including legal costs on an indemnity basis and all other liabilities of whatsoever nature or description which may be made or taken against or incurred by the +nsurer in relation to or arising out of the guarantee and)or this ,ounter8+ndemnity 0here any reDuest is made upon the +nsurer by M*M for payment of any sum pursuant to the @uarantee2 %Bsuch reDuestC' the insurer shall at its absolute discretion be at liberty to contest or compromise or immediately pay upon such reDuest and such reDuest shall be sufficient authority to the insurer for making any payment thereon without reDuiring or obtaining any evidence or proof that the amount so claimed or reDuested is due and payable to M*M and without any notice or reference to or further authority from me )us notwithstanding that +)we may dispute the validity of any such claim or reDuest +)0e shall not at any time Duestion or challenge the validity legality or otherwise of any payment made by the +nsurer to M*M pursuant to such reDuest or deny any liability under this ,ounter8+ndemnity on the ground that such payment or any part thereof made by the insurer was not due or payable under the @uarantee or on any other ground whatsoever +)0e shall not be discharged or released from this indemnity by any compromise2 variation or arrangement made between M*M and the +nsurer in relation to the obligation undertaken by the insurer under the guarantee or by any forbearance whether as to payment2 time2 performance or otherwise given by M*M to the insurer My)*ur liability hereunder is irrevocable and shall remain in full force and effect until the +nsurerFs liability under the @uarantee is fully discharged to the +nsurerFs satisfaction This indemnity shall be governed by and construed in accordance with the laws of "ingapore day of year

7 < 3 :

+n 0+T$1"" 0(1&1*F +)we have hereto subscribed my)our name%s' this

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA "ignature of 0itness Full $ame: $&+, $o : Address:

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA "ignature of !roposer Full $ame:

INSURANCE COVERAGES: PLAN ! Pre"iu": S#$%&' ( )GS* inc+uded, -or $& .ont/s 0 Pre"iu": S# 1%'21 )GS* inc+uded, -or % .ont/s Se,tion Co4erage Li-it 1. Letter o5 6uarantee to 7inistry o5 7anpo+er S85/000 2. 9ersonal 0,,i1ent %0& Deat) %:& 9er-anent Disable-ent %C& 7e1i,al e(penses Hospital ; Surgi,al 3(penses Daily :ene5it Repatriation 3(penses <ages ; Le4y Rei-burse-ent Re-Hiring 3(penses =utpatient >i1ney Dialysis * Can,er Spe,ial 6rant Rei-burse-ent o5 ?n1e-nity 9ai1 to ?nsurer S8!0/000 0s 9er S,ale in 9oli,y S81/000 S815/000 per annu.ot Co4ere1 S810/000 .ot Co4ere1 .ot Co4ere1 .ot Co4ere1 .ot Co4ere1 =ptional

3. !. 5. . 7. ". 9. 10.

PLAN $ ! Pre"iu": S#$&3'2( )GS* inc+uded, -or $& .ont/s 0 Pre"iu": S#$(('&4 )GS* inc+uded, -or % .ont/s Se,tion Co4erage Li-it 1. Letter o5 6uarantee to 7inistry o5 7anpo+er S85/000 2. 9ersonal 0,,i1ent %0& Deat) %:& 9er-anent Disable-ent %C& 7e1i,al e(penses Hospital ; Surgi,al 3(penses Daily :ene5it Repatriation 3(penses <ages ; Le4y Rei-burse-ent Re-Hiring 3(penses =utpatient >i1ney Dialysis * Can,er Spe,ial 6rant Rei-burse-ent o5 ?n1e-nity 9ai1 to ?nsurer S8!0/000 0s 9er S,ale in 9oli,y S82/000 S815/000 per annuS820 per 1ay %7a(i-u- 0 1ays& S810/000 2p to S830 9er 1ay %7a(i-u- 0 1ays& S8350 S82/500 %9oli,y Li-it& S81/000 =ptional

3. !. 5. . 7. ". 9. 10.

PLAN 4 ! Pre"iu": S#43%'2( )GS* inc+uded, -or $& .ont/s 0 Pre"iu": S#$1('11 )GS* inc+uded, -or % .ont/s Se,tion Co4erage Li-it 1. Letter o5 6uarantee to 7inistry o5 7anpo+er S85/000 2. 9ersonal 0,,i1ent %0& Deat) %:& 9er-anent Disable-ent %C& 7e1i,al e(penses Hospital ; Surgi,al 3(penses Daily :ene5it Repatriation 3(penses <ages ; Le4y Rei-burse-ent Re-Hiring 3(penses =utpatient >i1ney Dialysis * Can,er Spe,ial 6rant Rei-burse-ent o5 ?n1e-nity 9ai1 to ?nsurer S8!0/000 0s 9er S,ale in 9oli,y S83/000 S830/000 per annuS830 per 1ay %7a(i-u- 0 1ays& S810/000 2p to S830 9er 1ay %7a(i-u- 0 1ays& S8500 S85/000 %9oli,y Li-it& S83/000 =ptional

3. !. 5. . 7. ". 9. 10.

REI.BURSE.EN* O5 IN6E.NI*7 PAI6 *O INSURER )OP*IONAL, )Additiona+ Pre"iu": 5+at S#24'2( GS* inc+uded, ?n t)e e4ent t)at Liberty ?nsuran,e is re@uire1 to -aAe pay-ent un1er t)e Se,urity :on1 re@uire1 by 7inistry o5 7anpo+er/ t)e 9roposer +ill nee1 only rei-burse Liberty t)e B3(,essC a-ount/ pro4i1e1 t)at t)e pay-ent is not ,ause1 by or resulting 5ro- t)e 9roposerDs brea,) o5 t)e ,on1itions un1er t)e Se,urity :on1. #)e B3(,essC a-ount +ill 4ary as 5ollo+s$ %a& S8250*- i5 t)is e(tension o5 ,o4erage is pur,)ase1 +)en t)e insuran,e pa,Aage is 5irst arrange1. %b& S8500*- i5 t)is e(tension is pur,)ase1 -i1-ter- but +it)in one -ont) o5 t)e poli,y in,eption 1ate subEe,t to a +aiting perio1 o5 30 1ays 5ro- t)e 1ate o5 in,lusion.

Percentage of the cancellation refund will be as follows:

Within 60 days Between 61 to 120days Between 121 to 180 days !"ceeding 180days : Refund 80% : Refund 50% : Refund 0% : No Refund