AXXESS COVID-19 Insurance 2 * Indicates required fields. Please fill in the information of the Insured Person. PERKS HOLDINGS Name (as per NRIC) * NRIC # (eg., 901010105091)* Military/Police No. Date Of Birth # (eg., dd/mm/yyyy)* Gender* Please Select Male Female Email Address * Mobile No. (eg., 60123456789)* Please Select your Plan* Select your plan AXXESS Covid-19 Protect PLUS@RM36.50 AXXESS Covid-19 Protect@RM28.50 Total Amount (in MYR) Add Nomination? Yes No Name * NRIC* Military/Police No. Date Of Birth(dd/mm/yyyy)* Relationship* Distribution(%)* Nomination is MANDATORY if the Insured Person is below the age of 18 years old. Thank you By proceeding with payment you agree that you have read and agreed to the terms and conditions of coverage under the New AXXESS Covid-19 Insurance Plan 2.