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Form of a registered member.

You can fill out a registered member form to tarn a promotion and privileges when purchasing insurance with us with no cost to sign up.

Please enter your information in the form below.
(The lower part of the form marked "*" means information that you need to fill).


Personal information
Email Please enter E-mail *
Password Please enter Password *
Confirm Password Please enter Confirm Password *
Title
Please enter Prefix Name
Name Please enter Name *
Family name Please enter Surname *
References documentation
Date of Birth Please enter birth day *
Nationality Please enter Nationality *
Marital status Please enter status
Contact Address
Address Please enter address
Sub district/Tumbon Please enter district
District/Amphor Please enter Amphur
Province Please enter zipcode
Tel Please enter Telephone *
Mobile phone Please enter Mobile *
Fax Please enter Fax
Code 1 + 9
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Note: If you have completed information, it will be easy to buy insurance in the next
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