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"*" indicates required fields

1Customer Details
2Agent Details
3Device Info
4Payment
5Summary

Customer Details

Full name must be written as per NRIC.
Are you a Malaysian?*
Please ensure that the email given is accurate as the policy agreement will be sent to the email later.
Please ensure that the following mobile number is valid and accurate to ease the process of reaching out to customer regarding policy matters.
Consent
By submitting this application, you hereby agree to subscribe to Secondlifeasia Display Protection Plan. Secondlifeasia may collect, obtain, store, and process the data you have provided in this application form to receive updates, news, promotional and marketing emails, or materials from Secondlifeasia and subsidiary companies. You hereby give your consent to Secondlifeasia to store and process your Personal Data & transactional data as well as disclose your Personal Data & transactional data to the relevant governmental authorities or third parties where required by law or for legal purposes. In addition, your personal data may be transferred to any company within Secondlifeasia, which may involve sending your data to a location outside of Malaysia. For the purpose of updating or correcting such data, you may at any time apply to Secondlifeasia to have access to your personal data, which are stored by Secondlifeasia. For the avoidance of doubt, Personal Data includes all data defined within the Personal Data Protection Act 2010, including all data you had disclosed to Secondlifeasia in this form.

Agent Details

Kindly fill in the ID prescribed by the company. Please use the same Agent ID for all branches or locations.

Device Info

iPhone 13 Pro Max, MacBook Air 13” 2021, Apple Watch Series 7 41mm
Please provide an accurate serial number to ensure that a valid claim can be made based on the application.
DD slash MM slash YYYY
Payment*

Pay Over Counter/Online

Please confirm the customer details before the submission
{all_fields}
Confirmation of Details*