Group Life Insurance

Thank you for your interest in Three Balls Group Life Insurance! You’re now one step closer to securing valuable piece of mind yourself that your loved ones are always going to be protected.

Unlike typical brokerages, we don’t receive sales commissions and don’t recommend policies based solely on maximizing profits. Your health and financial security are our top priorities, and we are dedicated to helping you find the best coverage that meets your needs.

Name

HKID

Email Address

Phone number

I am an I am an Individual Business Owner

Date of birth

Gender Gender Male Female

Have you smoked in the last 12 months? Have you smoked in the last 12 months? Yes No

How many employees?

We will send you an email to provide details of your employees

Have you ever been diagnosed with? Have you ever been diagnosed with? Cancer or carcinoma in situ Heart disease Stroke Progressive neurological disorder (e.g. Motor neuron disease, Multiple sclerosis, Huntington's disease etc.)

In the last 5 years, have you suffered from any of these conditions? In the last 5 years, have you suffered from any of these conditions? Diabetes High blood pressure requiring treatment Raised cholesterol requiring treatment Asthma Any condition related to liver, kidneys or gallbladder Anxiety, panic attack or depression Attempted suicide Hospitalisation for more than 3 days (Excluding pregnancy or fractures)

Other than the previous answers, are you Other than the previous answers, are you Receiving any medical treatment, or awaiting investigation results or a hospital appointment Suffering any symptoms that you have sought medical advice?

Declaration Declaration I have never been refused life insurance I will answer to the best of my knowledge and belief, and my answers will be complete, truthful and accurate. I authorise Three Balls to use my information for the purposes of procuring group life insurance policy on behalf of group members. I am not obligated to purchase group critical illness cover even though I have expressed interest I am a Hong Kong resident