ACSI DSA Sportsmen Online Application
Kindly fill up all the details
Use the 'Tab' key or mouse to go to next field instead of 'Enter' key
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Name as in NRIC/FIN :
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NRIC/FIN No :
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Date of Birth(DD/MMM/YY) :
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Class in Year 2021 :
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CCA(s)
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Premium incl gst
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$60.00
(coverage from Date rcvd till 31/12/2020 for P6 going Sec 1)
(coverage from Date rcvd till 31/01/2021 for Sec 4 going JC1)
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Mode of Payment
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a) By Cheque Payable AB LIM PTE LTD, provide Cheque no
therafter post cheque to Blk 123 Bukit Merah Lane 1 #04-78 S(150123)
b) Bank Transfer (DBS Current 0060080073), provide Date & Time of transfer
Thereafter email Transfer confirmation to general@ablim.com.sg
c) Scan the QR code using PayNow, provide Date & Time of Payment
Thereafter email Payment confirmation to general@ablim.com.sg
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DATA PRIVACY STATEMENT AND DECLARATION
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In accordance with the Personal Data Protection Act 2012,
I/We consent to the collection, use, disclosure of and/or
process my/our personal data (whether contained in the Claim
Form or otherwise obtained) by Lonpac Insurance Bhd (”Lonpac”),
its affiliates and service providers (within or outside Singapore),
for the purpose relating to the evaluation of the claim and to provide
advice and information relating to the claim to me/us by Short Message Service (SMS),
Multimedia Messaging Service (MMS) and fax messages
(notwithstanding the registration of my/our telephone number(s) in the Singapore’s Do Not Call Registry).
Yes, I/we have read and agreed to the above Data Privacy Statement and I declare that
the information shown in this form is true and correct to the best of my knowledge.
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Instruction given by
Name of Parent/Guardian :
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Date :
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Resident Address :
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Mobile :
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Email Address :
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Please print a copy for your record before submission
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