Employee Name as per FIN *

FIN *

Date of Birth *

Race *

Nationality *

Gender *

Street Name

Block/Building No

Unit No

Postal Code *

Country

Contact Number *

PCP

Payment option*

Does your employee require medical examination in StarMed?*

YesNo

PCP Plan Subscribed

(Fee inclusive of GST)

PCP Start Date *

*For any dispute cases raised by customers to Stripe, all fees including processing fees chargeable by Stripe arising from these cases will be recharged to customers in the event that the dispute raised is invalid.