Personal Details (All fields required)

 


 


 

(e.g. 60121234567)

 
 

Prudential Details (All fields required)


 

 
 
 
 

Acknowledgement

I declare that the information given herein are correct to the best of my knowledge and belief. I agree to be governed by the rules and regulations of PRULIA as they now exist as they may hereafter be altered

I hereby authorize Prudential Assurance Malaysia Berhad to debit my commission account for the annual subscription

Click here for Authorization Code