www.aia.com.my
Open in
urlscan Pro
125.56.219.3
Public Scan
Submitted URL: https://9a58319fdb89454dbf7d57ec64124460.svc.dynamics.com/t/t/4hDslKU0vUrkzuT0OrDYVl69UoiPKtXeFbt0WzcaDS0x/SWuxMUwjBlmHlDCZD7mlnQaqxxnE1yr8YaUii8sbqG0x
Effective URL: https://www.aia.com.my/en/vitality-application.html
Submission: On June 20 via api from US — Scanned from SG
Effective URL: https://www.aia.com.my/en/vitality-application.html
Submission: On June 20 via api from US — Scanned from SG
Form analysis 2 forms found in the DOM
<form class="search-form" id="search-form1">
<input type="hidden" name="searchExecutor" value="/en/search" id="searchExecutor">
<input type="hidden" name="type" value="123" id="search_type">
<!--*/ end, by Ocean Lan */-->
<div class="search-col-left">
<input name="keyword" data-id="search-input" class="search-input" type="search" placeholder="Type your question" tabindex="9801"
data-search-options="{"hideAllFilter":false,"hideProductsFilter":false,"hideArticlesFilter":false,"hideFormsFilter":false}" autocomplete="off">
</div>
<div class="search-col-right">
<button class="btn btn-primary go-btn" tabindex="9802">Go</button>
<button class="btn dismiss-search-btn" tabindex="9803">
<svg title="Dismiss" class="icon icon-xs hide-on-fallback " role="img">
<g>
<title>Dismiss</title>
<use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="/content/dam/aia/icons/icons.svg#closewhite-glyph"></use>
<image class="icon icon-xs " src="/content/dam/aia/icons/glyph/closewhite-glyph.png" alt="undefined" xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href=""></image>
</g>
</svg>
</button>
</div>
</form>POST
<form id="form1403747038" method="POST">
<div class="form-page active" data-form-id="0">
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">Policy Product Type</label>
<input type="text" id="aia1787675462" name="PolicyProductTypeConfig" value="Vitality">
<div class="fieldError label-error" id="aia1787675462_msg"></div>
</div>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">Has Promotion</label>
<input type="text" id="aia682584753" name="promoEligibilityConfig" value="true">
<div class="fieldError label-error" id="aia682584753_msg"></div>
</div>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">Recurring Payment</label>
<input type="text" id="aia1737951732" name="RecurringPaymentConfig" value="true">
<div class="fieldError label-error" id="aia1737951732_msg"></div>
</div>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">No Promo Total Amount</label>
<input type="text" id="aia585676802" name="noPromoFixedTotalAmount" value="120.00">
<div class="fieldError label-error" id="aia585676802_msg"></div>
</div>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">No Promo Monthly Amount</label>
<input type="text" id="aia115989977" name="noPromoMonthlyAmount" value="10.00">
<div class="fieldError label-error" id="aia115989977_msg"></div>
</div>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">No Promo GST Amount</label>
<input type="text" id="aia1545658627" name="noPromoFixedGstAmount" value="0">
<div class="fieldError label-error" id="aia1545658627_msg"></div>
</div>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">No Promo Total Free Month</label>
<input type="text" id="aia1331874589" name="noPromoFixedTotalFreeMonth" value="0">
<div class="fieldError label-error" id="aia1331874589_msg"></div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row review-quote-details-cont">
<div class="col col-md-6 col-sm-10 col-xs-10 col-md-offset-3 col-sm-offset-1 col-xs-offset-1 ">
<div>
<div class="hidden section"><input id="new_form_hidden_856291934" name="hidden_856291934" value="" type="hidden">
</div>
<div class="hidden section"><input id="new_form_hidden_1510216012" name="hidden_1510216012" value="" type="hidden">
</div>
<div class="hidden section"><input id="new_form_hidden" name="hidden" value="" type="hidden">
</div>
<div class="sub-title section">
<h3 class="h3 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-4xl margin-bottom-l">AIA Vitality Membership Application</h3>
</div>
<div class="sub-title section">
<h4 class="h4 p3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">Are You Eligible?</h4>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>Please key-in the following details to verify if you are <b>eligible</b> to apply for the AIA Vitality Membership.</p>
</div>
</div>
<div class="text parbase section">
<label id="text-id1290343264" form-target-name="identityNo" for=" ">
<div class="aia-text text-left p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Identification no.</p>
</div>
</label>
</div>
<div class="form-toggle-box form-base section">
<input type="hidden" id="toggle-group-1129563152" name="IdentificationType" value="NRIC" required="true">
<div data-target="toggle-group" class="btn-toggle-group parent-width" id="1129563152" name="IdentificationType">
<button type="button" class="btn btn-toggle btn-selected" value="NRIC">NEW NRIC</button>
<button type="button" class="btn btn-toggle " value="other">other</button>
</div>
<div id="toggle-group-1129563152" class="fieldError label-error" requiredmessage="This field is required."></div>
<script type="text/javascript">
// Toggle buttons init
$("body").ready(function() {
$("#1129563152 .btn-toggle").off("click");
$("#1129563152").each(function(i, e) {
var groupID = $(e).attr("id");
$(this).find(".btn-toggle").on('click', function(e) {
$("#toggle-group-" + groupID).attr("value", $(this).attr("value"));
var toggleButtons = $("#" + groupID + " .btn-toggle");
var selectedToggleButtons = $("#" + groupID + " .btn-toggle.btn-selected");
var currentToggleIndex = toggleButtons.index(this);
selectToggleButton1129563152(toggleButtons, currentToggleIndex);
});
});
});
</script>
<script type="text/javascript">
function selectToggleButton1129563152(toggleButtons, currentToggleIndex) {
toggleButtons.removeClass("btn-selected");
toggleButtons.eq(currentToggleIndex).addClass("btn-selected");
}
</script>
</div>
<div class="grid-control-1-col section">
<div class="row margin-top-l">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia1074644344" name="IdentificationNo" placeholder="e.g. 880506013366" required="true"
re="([0-9][0-9])((0[1-9])|(1[0-2]))((0[1-9])|([1-2][0-9])|(3[0-1]))([0-9][0-9])([0-9][0-9][0-9][0-9])" validationtype="text" maxlength="12">
<div class="fieldError label-error" id="aia1074644344_msg" requiredmessage="This is a required field." remessage="Please enter valid Identification No."></div>
</div>
<div class="html-script section">
<div class="label-error nric-error"></div>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row dob-container ">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<label id="text-id247911472" form-target-name="dob" for=" ">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Date of birth</p>
</div>
</label>
</div>
<div class="grid-control-3-col section">
<div class="row dob-wrapper">
<div class="col col-md-3 col-sm-3 col-xs-4 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 no-padding-md no-padding-sm no-padding-xs">
<div>
<div class="grid-control-1-col section">
<div class="row margin-bottom-md-xxs margin-bottom-sm-xxs margin-bottom-s">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="dob_day" id="aia991817510" style="color: #;" disabled="disabled">
<option value="" disabled="" selected="" data-option-placeholder="">Day</option>
<option value="01" style="color: rgb(85, 67, 68);">01</option>
<option value="02" style="color: rgb(85, 67, 68);">02</option>
<option value="03" style="color: rgb(85, 67, 68);">03</option>
<option value="04" style="color: rgb(85, 67, 68);">04</option>
<option value="05" style="color: rgb(85, 67, 68);">05</option>
<option value="06" style="color: rgb(85, 67, 68);">06</option>
<option value="07" style="color: rgb(85, 67, 68);">07</option>
<option value="08" style="color: rgb(85, 67, 68);">08</option>
<option value="09" style="color: rgb(85, 67, 68);">09</option>
<option value="10" style="color: rgb(85, 67, 68);">10</option>
<option value="11" style="color: rgb(85, 67, 68);">11</option>
<option value="12" style="color: rgb(85, 67, 68);">12</option>
<option value="13" style="color: rgb(85, 67, 68);">13</option>
<option value="14" style="color: rgb(85, 67, 68);">14</option>
<option value="15" style="color: rgb(85, 67, 68);">15</option>
<option value="16" style="color: rgb(85, 67, 68);">16</option>
<option value="17" style="color: rgb(85, 67, 68);">17</option>
<option value="18" style="color: rgb(85, 67, 68);">18</option>
<option value="19" style="color: rgb(85, 67, 68);">19</option>
<option value="20" style="color: rgb(85, 67, 68);">20</option>
<option value="21" style="color: rgb(85, 67, 68);">21</option>
<option value="22" style="color: rgb(85, 67, 68);">22</option>
<option value="23" style="color: rgb(85, 67, 68);">23</option>
<option value="24" style="color: rgb(85, 67, 68);">24</option>
<option value="25" style="color: rgb(85, 67, 68);">25</option>
<option value="26" style="color: rgb(85, 67, 68);">26</option>
<option value="27" style="color: rgb(85, 67, 68);">27</option>
<option value="28" style="color: rgb(85, 67, 68);">28</option>
<option value="29" style="color: rgb(85, 67, 68);">29</option>
<option value="30" style="color: rgb(85, 67, 68);">30</option>
<option value="31" style="color: rgb(85, 67, 68);">31</option>
</select>
<div class="fieldError label-error" id="aia991817510_msg"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia991817510").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia991817510").css('color', '#554344');
}
});
$("#aia991817510").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col col-md-3 col-sm-3 col-xs-4 no-padding-md no-padding-sm no-padding-xs">
<div>
<div class="grid-control-1-col section">
<div class="row margin-bottom-md-xxs margin-bottom-sm-xxs margin-bottom-s">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="dob_month" id="aia640986489" style="color: #;" disabled="disabled">
<option value="" disabled="" selected="" data-option-placeholder="">Month</option>
<option value="01" style="color: rgb(85, 67, 68);">Jan</option>
<option value="02" style="color: rgb(85, 67, 68);">Feb</option>
<option value="03" style="color: rgb(85, 67, 68);">Mar</option>
<option value="04" style="color: rgb(85, 67, 68);">Apr</option>
<option value="05" style="color: rgb(85, 67, 68);">May</option>
<option value="06" style="color: rgb(85, 67, 68);">Jun</option>
<option value="07" style="color: rgb(85, 67, 68);">Jul</option>
<option value="08" style="color: rgb(85, 67, 68);">Aug</option>
<option value="09" style="color: rgb(85, 67, 68);">Sep</option>
<option value="10" style="color: rgb(85, 67, 68);">Oct</option>
<option value="11" style="color: rgb(85, 67, 68);">Nov</option>
<option value="12" style="color: rgb(85, 67, 68);">Dec</option>
</select>
<div class="fieldError label-error" id="aia640986489_msg"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia640986489").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia640986489").css('color', '#554344');
}
});
$("#aia640986489").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col col-md-3 col-sm-3 col-xs-4 no-padding-md no-padding-sm no-padding-xs">
<div>
<div class="grid-control-1-col section">
<div class="row margin-bottom-md-xxs margin-bottom-sm-xxs margin-bottom-s">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="dob_year" id="aia2021176808" style="color: #;" disabled="disabled">
<option value="" disabled="" selected="" data-option-placeholder="">Year</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
</select>
<div class="fieldError label-error" id="aia2021176808_msg"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia2021176808").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia2021176808").css('color', '#554344');
}
});
$("#aia2021176808").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<div class="label-error dob-err-msg">
</div>
</div>
<div class="html-script section">
<div id="maintenance-err-msg" class="label-error maintenance-err-msg" style="display: none;"></div>
</div>
<div class="html-script section">
<style>
.dob-wrapper .primary-select[disabled] {
background-color: #EEEFF0;
border-color: #D6D8DA;
color: #969BA0;
background-image: 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');
}
</style>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row margin-top-l">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="line-divider section">
<hr class=" margin-bottom-md-l margin-bottom-sm-l margin-bottom-l ">
</div>
<div class="sub-title section">
<h4 class="h4 p3 margin-top-xl margin-bottom-l">Have A Promo Code?</h4>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>Please key-in the promo code to redeem for free trial. This field is optional.</p>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Promo Code</p>
</div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia18858306" name="promoCode" placeholder="e.g. vitality1234" re="^[a-zA-Z0-9]+$" validationtype="text">
<div class="fieldError label-error" id="aia18858306_msg" remessage="Promo code contains invalid characters."></div>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<br>
<div class="g-recaptcha" data-sitekey="6Lf-aGclAAAAABEpnqFkMdSJcjUC03FHARqXL1uO">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-x5ojil6x8ffs" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Lf-aGclAAAAABEpnqFkMdSJcjUC03FHARqXL1uO&co=aHR0cHM6Ly93d3cuYWlhLmNvbS5teTo0NDM.&hl=en&v=KXX4ARWFlYTftefkdODAYWZh&size=normal&cb=2qa4kn4gup1t"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div>
</div>
<script>
$(function() {
var captchaKey = [{
'domain': 'wwwuat2.aia.com.my',
'key': '6LcraGclAAAAAGbYOXDJ-0EWVWZwg2W0vhrmG8bL'
}, {
'domain': 'www.aia.com.my',
'key': '6Lf-aGclAAAAABEpnqFkMdSJcjUC03FHARqXL1uO'
}, {
'domain': 'localhost',
'key': '6LcraGclAAAAAGbYOXDJ-0EWVWZwg2W0vhrmG8bL'
}]
var getHost = window.location.hostname;
var result = captchaKey.filter(a => a.domain.indexOf(getHost) !== -1);
$('.g-recaptcha').attr('data-sitekey', result[0].key);
})
</script>
</div>
<div class="html-script section">
<script>
$(function() {
$('input[name="g-recaptcha-check"]').parent().children(':not(div)').hide();
$('input[name="g-recaptcha-check"]').parent().show();
setTimeout(function() {
$('.check-eligibility-btn button').bind("click mouseenter mouseleave", function() {
$('input[name="g-recaptcha-check"]').val($('[name="g-recaptcha-response"]').val());
});
}, 3000)
});
</script>
<script src="https://www.google.com/recaptcha/api.js" defer=""></script>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia72614098" name="g-recaptcha-check" required="true" validationtype="text" style="display: none;">
<div class="fieldError label-error" id="aia72614098_msg" requiredmessage="*Please verify the reCAPTCHA and tick the check box before submission"></div>
</div>
<div class="html-script section">
<p data-validation="return-error-message" class="bt4 u2 text-center generic-form-validation margin-top-l label-error "></p>
</div>
<div class="html-script section">
<label for="eligibilityTnc" class="checkbox margin-bottom-xxs">
<input type="checkbox" index="0" value="eligibilityTncYes" name="disclosure_consent" groupid="840236892" id="eligibilityTnc" required="">
<span class="indicator"><span class="tick"></span></span>
<span class="p3">By clicking "CHECK MY ELIGIBILITY", you understand and agree that your information collected above may be held and used by AIA Health Services Sdn. Bhd. ("AHS"). For full terms and conditions, please click <span
class="eligibility-tnc-popup" style="cursor: pointer; color: #3366CC; text-decoration: underline #3366CC;">HERE</span>.</span>
</label>
<div id="840236892_msg" class="fieldError label-error margin-bottom-l" requiredmessage="This is a required field."></div>
</div>
<div class="html-script section">
<div class="label-error vitality-eligibility-err-msg"></div>
<div id="maintenance-err-msg" class="label-error maintenance-err-msg" style="display: none;"> Dear customers, please be informed that we will be performing major systems upgrade from Friday, 5 May 11:00 PM(MYT) till Saturday, 6 May
3:00PM (MYT) Sorry for the inconvenient </div>
<script>
$('.check-eligibility-btn').show();
$('.maintenance-err-msg').hide();
</script>
</div>
<div class="button aiabase parbase section">
<div class="margin-top-l margin-bottom-4xl check-eligibility-btn">
<div>
<button id="btn58773257" class="btn btn-default btn-primary " type="button" onclick="buttonClick(this)" data-target="_self">Check my eligibility</button>
</div>
</div>
</div>
<div class="hidden section"><input id="new_form_hidden_1063125123" name="hidden_1063125123" value="" type="hidden">
</div>
<div class="html-script section">
<style>
.btn-trigger-invalid-promo-code {
display: none;
}
.vitality-eligibility-err-msg {
margin-top: 5px;
}
</style>
</div>
<div class="button aiabase parbase section">
<div class="margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-top-0 margin-bottom-0 btn-trigger-invalid-promo-code">
<div>
<button id="btn615696538" class="btn btn-default btn-primary " type="button" onclick="buttonClick(this)" data-link="/content/my/en/tools/vitality-std-invalid-promo-code" data-target="#btn-modal-615696538"
data-toggle="modal">Trigger Invalid promo code</button>
</div>
</div>
</div>
<div class="button aiabase parbase section">
<div class="margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-top-0 margin-bottom-0 btn-trigger-eligibilitytnc-overlay hidden">
<div>
<button id="btn114209985" class="btn btn-default btn-primary " type="button" onclick="buttonClick(this)" data-link="/content/my/en/tools/eligibility-tnc-overlay" data-target="#btn-modal-114209985" data-toggle="modal">Trigger
Eligibility Tnc Overlay</button>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class=" form-page" data-form-id="1">
<div class="grid-control-2-col section">
<div class="row review-quote-details-cont two-col">
<div class="col col-md-7 col-sm-7 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="section-container section">
<section style="background-color:bg-w;">
<div class="container ">
<div>
<div class="grid-control-1-col section">
<div class="row margin-top-xl margin-bottom-xxl progressBar personalProgress">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-progressline section">
<ul class="progress-line">
<li class="current-step">
<span class="step-number">1</span>
</li>
<li>
<span class="step-number">2</span>
</li>
<li>
<span class="step-number">3</span>
</li>
</ul>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<div class="label-error vitality-appl-err-msg"></div>
</div>
<div class="grid-control-1-col section">
<div class="row full-form-sec-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="grid-control-1-col section">
<div class="row vitality-title-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h3 class="h3 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-l">{{title}}</h3>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row no-promo-text-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h5 class="h5 p3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">Yes! you are eligible to apply</h5>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row promo-text-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h5 class="h5 p3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">GREAT NEWS! YOU ARE ENTITLED TO A 12-MONTH FREE AIA VITALITY MEMBERSHIP</h5>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row short-form-sec-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h3 class="h3 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-l">REACTIVATE your membership</h3>
</div>
<div class="grid-control-1-col section">
<div class="row no-promo-text-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h5 class="h5 p3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">OOPS SORRY! YOUR AIA VITALITY MEMBERSHIP HAS EXPIRED.</h5>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row promo-text-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h5 class="h5 p3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">CONGRATULATIONS! YOU ARE ENTITLED TO A 12-MONTH FREE AIA VITALITY MEMBERSHIP</h5>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>To continue enjoying great benefits as an AIA Vitality member, you can reactivate your membership by updating your details below and proceed with membership fee payment. Please note that once you have successfully
reactivated your membership, your AIA Vitality Status and points will automatically reset to Bronze and "0" points.<br> </p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row vitality-small-title-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h4 class="h4 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-xxl margin-bottom-m">{{title}}</h4>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>Please key-in the following details:</p>
</div>
</div>
<div class="text parbase section">
<label id="text-id1172306702" form-target-name="fullName" for="aia1050382840">
<div class="aia-text text-left p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Name (as per NRIC/ Passport)</p>
</div>
</label>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia1050382840" name="fullName" placeholder="e.g. John Doe" required="true" re="^[a-zA-Z @'/-]{1,250}$" validationtype="text">
<div class="fieldError label-error" id="aia1050382840_msg" requiredmessage="This is a required field."
remessage="Full Name contains invalid characters. Valid characters are A to Z, a to z, hyphen (-), space ( ) and apostrophe (')."></div>
</div>
<div class="grid-control-1-col section">
<div class="row full-form-sec-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<label id="text-id712051660" form-target-name="fullName" for="aia1050382840">
<div class="aia-text text-left p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Gender</p>
</div>
</label>
</div>
<div class="form-toggle-box form-base section">
<input type="hidden" id="toggle-group-689992792" name="gender" value="" required="true">
<div data-target="toggle-group" class="btn-toggle-group parent-width" id="689992792" name="gender">
<button type="button" class="btn btn-toggle" value="M">MALE</button>
<button type="button" class="btn btn-toggle " value="F">FEMALE</button>
</div>
<div id="toggle-group-689992792" class="fieldError label-error" requiredmessage="This is a required field."></div>
<script type="text/javascript">
// Toggle buttons init
$("body").ready(function() {
$("#689992792 .btn-toggle").off("click");
$("#689992792").each(function(i, e) {
var groupID = $(e).attr("id");
$(this).find(".btn-toggle").on('click', function(e) {
$("#toggle-group-" + groupID).attr("value", $(this).attr("value"));
var toggleButtons = $("#" + groupID + " .btn-toggle");
var selectedToggleButtons = $("#" + groupID + " .btn-toggle.btn-selected");
var currentToggleIndex = toggleButtons.index(this);
selectToggleButton689992792(toggleButtons, currentToggleIndex);
});
});
});
</script>
<script type="text/javascript">
function selectToggleButton689992792(toggleButtons, currentToggleIndex) {
toggleButtons.removeClass("btn-selected");
toggleButtons.eq(currentToggleIndex).addClass("btn-selected");
}
</script>
</div>
<div class="html-script section">
<div class="label-error gender-err-msg"></div>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<label id="text-id973826656" form-target-name="fullName" for="aia1050382840">
<div class="aia-text text-left p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Mobile Number</p>
</div>
</label>
</div>
<div class="grid-control-2-col section">
<div class="row review-mobile-cont">
<div class="col col-md-4 col-sm-5 col-xs-5 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="mobCountryList" id="aia105117120" required="true" style="color: #;">
<option style="color: rgb(85, 67, 68);">Please Select</option>
</select>
<div class="fieldError label-error" id="aia105117120_msg" requiredmessage="Please select your country calling code."></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia105117120").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia105117120").css('color', '#554344');
}
});
$("#aia105117120").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
</div>
</div>
<div class="col col-md-8 col-sm-7 col-xs-7 ">
<div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia2051315954" name="newMobileNo" placeholder="e.g. 163456789" required="true" re="^[0-9]{5,16}$" validationtype="text">
<div class="fieldError label-error" id="aia2051315954_msg" requiredmessage="This is a required field." remessage="Please enter valid mobile number."></div>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Email Address</p>
</div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia520315865" name="emailAdd" placeholder="e.g. john.doe@email.com" required="true" re="^[a-zA-Z0-9.!#$%&’*+/=?^_`{|}~-]+@[a-zA-Z0-9-]+(?:\.[a-zA-Z0-9-]+)*$"
validationtype="text">
<div class="fieldError label-error" id="aia520315865_msg" requiredmessage="Please enter your email." remessage="Please enter a valid email address."></div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Confirm Your Email Address</p>
</div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia638072271" name="confirmEmail" placeholder="e.g. john.doe@email.com" required="true" re="^[a-zA-Z0-9.!#$%&’*+/=?^_`{|}~-]+@[a-zA-Z0-9-]+(?:\.[a-zA-Z0-9-]+)*$"
validationtype="text">
<div class="fieldError label-error" id="aia638072271_msg" requiredmessage="Please enter your email." remessage="Please enter a valid email address."></div>
</div>
<div class="html-script section">
<div class="label-error confirm-email-err-msg"></div>
</div>
<div class="grid-control-1-col section">
<div class="row full-form-sec-cont address-input-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Address</p>
</div>
</div>
<div class="html-script section">
<style>
input[name="address2"],
input[name="address3"] {
margin-top: 15px;
}
</style>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia593252361" name="address1" placeholder="Unit or Building No." required="true" re="^[a-zA-Z0-9-' #/,.:;/'$&_!@(){}/\[\//\]\\/]{1,250}$"
validationtype="text">
<div class="fieldError label-error" id="aia593252361_msg" requiredmessage="Please enter your address (line 1)." remessage="This field contains invalid characters."></div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia1239262452" name="address2" placeholder="Street Name" required="true" re="^[a-zA-Z0-9-' #/,.:;/'$&_!@(){}/\[\//\]\\/]{1,250}$" validationtype="text">
<div class="fieldError label-error" id="aia1239262452_msg" requiredmessage="Please enter your address (line 2)." remessage="This field contains invalid characters."></div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia1009377764" name="address3" placeholder="Town/City" re="^[a-zA-Z0-9-' #/,.:;/'$&_!@(){}/\[\//\]\\/]{1,250}$" validationtype="text">
<div class="fieldError label-error" id="aia1009377764_msg" remessage="This field contains invalid characters."></div>
</div>
<div class="grid-control-2-col section">
<div class="row ">
<div class="col col-md-6 col-sm-6 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">State</p>
</div>
</div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="state" id="aia286296064" required="true" style="color: #;">
<option value="" disabled="" selected="" data-option-placeholder="">Please Select</option>
</select>
<div class="fieldError label-error" id="aia286296064_msg" requiredmessage="Please select your state."></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia286296064").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia286296064").css('color', '#554344');
}
});
$("#aia286296064").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
</div>
</div>
<div class="col col-md-6 col-sm-6 col-xs-12 ">
<div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Postcode</p>
</div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia1787630690" name="postcode" placeholder="e.g. 55100" required="true" re="^[0-9]+$" validationtype="text" maxlength="5">
<div class="fieldError label-error" id="aia1787630690_msg" requiredmessage="This is a required field." remessage="Postcode contains invalid characters. Valid characters are 0 to 9."></div>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Country</p>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-s" data-emptytext="Text">
<p><b>Malaysia</b></p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row margin-top-l create-profile-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h4 class="h4 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-m">Create your online profile</h4>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>These details will be your login information to access both the MY AIA and AIA Vitality portals and mobile apps</p>
</div>
</div>
<div class="text parbase section">
<label id="text-id317816307" form-target-name="dob" for=" ">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">User ID</p>
</div>
</label>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia2136168698" name="username" placeholder="Enter user ID" required="true" validationtype="text"
style="background: url("/content/dam/my/en/1a1p/my-insurance/images/icons/icons-complete-grey.png") 97% 50% / 18px no-repeat; padding-right: 25px;">
<div class="fieldError label-error" id="aia2136168698_msg" requiredmessage="This is a required field."></div>
</div>
<div class="html-script section">
<div class="label-error username-err"></div>
</div>
<div class="html-script section">
<div class="margin-top-l" style="display: flex; justify-content: space-between;">
<div class="bt3"> Enter Your Password </div>
<div class="form-checkbox form-base section">
<label class="checkbox margin-bottom-s" for="16934908761">
<input type="checkbox" id="16934908761" groupid="969374021" name="chxShowPassword" value="showPassword" index="0">
<span class="indicator"><span class="tick"></span></span>
<span>Show Password</span>
</label>
<div id="969374021_msg" class="fieldError label-error"></div>
</div>
</div>
</div>
<div class="form-input form-base section">
<input type="password" class="primary-select parent-width" id="aia169811529" name="password" placeholder="Enter password" required="true" validationtype="text" autocomplete="off"
style="background: url("/content/dam/my/en/1a1p/my-insurance/images/icons/icons-complete-grey.png") 97% 50% / 18px no-repeat; padding-right: 25px;">
<div class="fieldError label-error" id="aia169811529_msg" requiredmessage="Please enter your password."></div>
</div>
<div class="html-script section">
<div id="pw-criteria-box">
<p>Your password must:</p>
<ul>
<li id="pw-criteria_hasMinLength">
<div class="bullet">•</div>
<div class="validation-text minLength">Have at least 9 characters with no space</div>
</li>
<li id="pw-criteria_oneUpperCase">
<div class="bullet">•</div>
<div class="validation-text uppercase">Contain at least one uppercase letters (A-Z)</div>
</li>
<li id="pw-criteria_oneLowerCase">
<div class="bullet">•</div>
<div class="validation-text lowercase">Contain at least one lowercase letters (a-z)</div>
</li>
<li id="pw-criteria_oneSpecialChar">
<div class="bullet">•</div>
<div class="validation-text specialchar">Contain at least one special characters (eg: ~!@#$%^&*_-+=`|\(){}[]:;”’<>,.?/)</div>
</li>
<li id="pw-criteria_noUserId">
<div class="bullet">•</div>
<div class="validation-text userid">NOT contain your User ID</div>
</li>
</ul>
</div>
<style>
#pw-criteria-box {
margin: 2% 0;
}
#pw-criteria-box ul {
line-height: 1;
list-style: none;
}
#pw-criteria-box ul li {
display: flex;
}
#pw-criteria-box ul li .bullet {
margin-right: 10px;
font-size: 30px;
color: #B7123E;
}
.validation-text {
margin-top: 15px;
}
</style>
</div>
<div class="html-script section">
<div class="label-error pwor-err margin-bottom-xxl"></div>
</div>
<div class="html-script section">
<div class="label-error password-err"></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
</div>
</div>
</div>
<div class="col col-md-5 col-sm-5 col-xs-12 ">
<div>
<div class="section-container section">
<section style="background-color:rgb(240,238,225);">
<div class="container ">
<div>
<div class="sub-title section">
<h6 class="h6 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-xxl margin-bottom-m">Quote</h6>
</div>
<div class="grid-control-2-col section">
<div class="row step-1-fee-cont">
<div class="col col-md-6 col-sm-6 col-xs-6 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h4 class="h4 p4 margin-bottom-md-l margin-bottom-sm-l">Membership Fee</h4>
</div>
</div>
</div>
<div class="col col-md-6 col-sm-6 col-xs-6 ">
<div>
<div class="sub-title section">
<h4 class="h4 text-right p4 margin-bottom-md-l margin-bottom-sm-l">{{TotalAmountWithCurrency}}</h4>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<hr style="background: #363E3F;" class="margin-bottom-l margin-top-l margin-top-sm-0">
</div>
<div class="grid-control-1-col section">
<div class="row margin-left-0 side-title-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h5 class="h5 text-left p4 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">{{sideTitle}}</h5>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-2-col section">
<div class="row margin-left-0 step-1-membership-duration-cont">
<div class="col col-md-6 col-sm-6 col-xs-6 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l" data-emptytext="Text">
<p>Membership Duration</p>
</div>
</div>
</div>
</div>
<div class="col col-md-6 col-sm-6 col-xs-6 ">
<div>
<div class="text parbase section">
<div class="aia-text text-right p4 bt3 margin-bottom-md-l margin-bottom-sm-l" data-emptytext="Text">
<p>{{membershipDuration}}</p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>Please tick the boxes below to proceed:<br> </p>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row margin-bottom-l">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="html-script section">
<style>
label.checkbox input[type="checkbox"]+span {
display: inline-block;
vertical-align: top;
margin-top: 4px;
}
label.checkbox .p3 {
display: inline-block;
width: 88%;
}
@media (max-width: 950px) {
label.checkbox .p3 {
width: 83%;
}
}
@media (max-width: 480px) {
label.checkbox .p3 {
width: 80%;
}
}
</style>
</div>
<div class="html-script section">
<label for="2213655175tnc" class="checkbox margin-bottom-xxs">
<input type="checkbox" index="0" value="yes" name="tnc" groupid="840236892" id="2213655175tnc" required="">
<span class="indicator"><span class="tick"></span></span>
<span class="p3">I understand and agree to the AIA Vitality Membership <a class="lk2" href="/en/vitality-application1/terms-and-conditions.html" target="_blank">Terms & Conditions</a> and
<a class="lk2" href="/en/index/privacy-statement.html" target="_blank">Privacy Statement</a>.</span>
</label>
<div id="840236892_msg" class="fieldError label-error margin-bottom-l" requiredmessage="This is a required field."></div>
</div>
<div class="form-checkbox form-base section">
<label class="checkbox margin-bottom-s" for="1367898821">
<input type="checkbox" id="1367898821" groupid="1965848637" name="marketing_consent" value="info_ahs" index="0">
<span class="indicator"><span class="tick"></span></span>
<span class="p3">I agree that any personal information collected or held by AIA Malaysia (AIA Malaysia refers to AIA Bhd, AIA Public Takaful Berhad, AIA General Berhad, AIA Health Services Sdn Bhd and AIA Pension and
Asset Management Sdn Bhd,) (whether contained in this application or otherwise obtained) may be disclosed by AIA Malaysia to any selected third party for the purposes of cross marketing, direct marketing and data
matching and to communicate with me for such purposes. I understand that I have a right to obtain access to and to request correction of any personal information held by AIA Malaysia concerning me. Such request can
be made to any of AIA’s Customer Service Centre. </span>
</label>
<div id="1965848637_msg" class="fieldError label-error"></div>
</div>
<div class="html-script section">
<label for="2213655204" class="checkbox margin-bottom-xxs create-acct-label">
<input type="checkbox" index="0" value="agreeCreate" name="creating_term" groupid="840236892create" id="2213655204" required="">
<span class="indicator"><span class="tick"></span></span>
<span class="p3">By creating a My AIA account, I agree to AIA's <a href="/en/my-aia/terms-of-use.html" target="_blank" class="lk2">Terms of Use</a>.</span>
</label>
<div id="840236892create_msg" class="fieldError label-error margin-bottom-l" requiredmessage="This is a required field."></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
</div>
</div>
</div>
</div>
</div>
</div>
<div class=" form-page" data-form-id="2">
<div class="grid-control-1-col section">
<div class="row margin-top-xxl margin-bottom-xxl loading-icon-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="icon section">
<div style="text-align:center;">
<svg class="icon icon-m hide-on-fallback " role="img">
<g>
<use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="/content/dam/aia/icons/icons.svg#yellow25-ring"></use>
<image class="icon icon-m " src="/content/dam/aia/icons/progress-rings/yellow25-ring.png" alt="null" xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href=""></image>
</g>
</svg>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<style>
.loading-icon-cont {
display: none;
}
.loading-icon-cont svg {
animation: spin 2s linear infinite;
}
@keyframes spin {
0% {
transform: rotate(0deg);
}
100% {
transform: rotate(360deg);
}
}
</style>
</div>
<div class="grid-control-2-col section">
<div class="row review-quote-details-cont two-col step-2-confirm-cont">
<div class="col col-md-7 col-sm-7 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="section-container section">
<section style="background-color:bg-w;">
<div class="container ">
<div>
<div class="grid-control-1-col section">
<div class="row margin-top-xl margin-bottom-xxl progressBar personalProgress">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-progressline section">
<ul class="progress-line">
<li class="completed-step">
<span class="step-number">1</span>
</li>
<li class="current-step">
<span class="step-number">2</span>
</li>
<li>
<span class="step-number">3</span>
</li>
</ul>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<div class="label-error comfirm-purchase-err-msg"></div>
</div>
<div class="sub-title section">
<h3 class="h3 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-l">{{title}}</h3>
</div>
<div class="sub-title section">
<h4 class="h4 p3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">{{summaryTitleText}}</h4>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>Please fill up the following details:</p>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<ul class="review-summary-list">
<li>Name (as per NRIC/ Passport)</li>
<li><b>{{CustomerDetails.CustomerName}}</b></li>
</ul>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<ul class="review-summary-list full-form-sec-cont">
<li>Gender</li>
<li><b>{{#GENDER}}{{CustomerDetails.Gender}}{{/GENDER}}</b></li>
</ul>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<ul class="review-summary-list">
<li>Mobile Number</li>
<li><b>{{CustomerDetails.MobTel}}</b></li>
</ul>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<ul class="review-summary-list">
<li>Email Address</li>
<li><b>{{CustomerDetails.Email}}</b></li>
</ul>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<ul class="review-summary-list full-form-sec-cont">
<li>Address</li>
<li><b>{{CustomerDetails.Add1}} {{CustomerDetails.Add2}} {{CustomerDetails.Add3}} {{CustomerDetails.Postcode}}, {{CustomerDetails.State}}, {{CustomerDetails.Country}}<br> </b></li>
</ul>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-top-sm-l margin-top-l margin-bottom-xxl" data-emptytext="Text">
<ul class="review-summary-list create-profile-cont">
<li>Username</li>
<li><b>{{AccountRegistration.Username}}</b></li>
</ul>
</div>
</div>
</div>
</div>
</section>
</div>
</div>
</div>
<div class="col col-md-5 col-sm-5 col-xs-12 ">
<div>
<div class="section-container section">
<section style="background-color:rgb(240,238,225);">
<div class="container ">
<div>
<div class="sub-title section">
<h6 class="h6 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-xxl margin-bottom-m">Quote</h6>
</div>
<div class="grid-control-2-col section">
<div class="row ">
<div class="col col-md-6 col-sm-6 col-xs-6 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h4 class="h4 p4 margin-bottom-md-l margin-bottom-sm-l">Membership Fee</h4>
</div>
</div>
</div>
<div class="col col-md-6 col-sm-6 col-xs-6 ">
<div>
<div class="sub-title section">
<h4 class="h4 text-right p4 margin-bottom-md-l margin-bottom-sm-l">{{TotalAmountWithCurrency}}</h4>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<hr style="background: #363E3F;" class="margin-bottom-l margin-top-l margin-top-sm-0">
</div>
<div class="grid-control-1-col section">
<div class="row margin-left-0">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="sub-title section">
<h5 class="h5 text-left p4 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">{{sideTitle}}</h5>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-2-col section">
<div class="row margin-left-0">
<div class="col col-md-6 col-sm-6 col-xs-6 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>Membership Duration</p>
</div>
</div>
</div>
</div>
<div class="col col-md-6 col-sm-6 col-xs-6 ">
<div>
<div class="text parbase section">
<div class="aia-text text-right p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>{{membershipDuration}}</p>
<p> </p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<div class="padding-left-s padding-right-s padding-top-s padding-bottom-s bg-b2 auto-renewal-cont">
<label for="autoRenewalCheckbox" class="checkbox margin-bottom-xxs">
<input type="checkbox" index="0" value="y" name="autoRenewal" groupid="840236893Auto" id="autoRenewalCheckbox" required="">
<span class="indicator"><span class="tick"></span></span>
<span class="p3"><span class="p6" style="display:inline-block; margin-top:5px;"><strong>Auto Renewal</strong></span><br><br>Your registered credit/debit card will be charged on a monthly basis from month <span
class="auto-renewal-month-text">13th</span> onwards.</span>
</label>
<div id="840236893Auto_msg" class="fieldError label-error margin-bottom-l" requiredmessage="AIA Vitality requires you to sign up for Auto Renewal to avoid interruptions to your member benefits."></div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-top-0 margin-bottom-0 cc-tnc-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>Please tick the boxes below to proceed:<br> </p>
</div>
</div>
<div class="html-script section">
<label for="21182642191" class="checkbox margin-bottom-xxs">
<input type="checkbox" index="0" value="agreeCreate" name="agreeCredit" groupid="840236892Agree" id="21182642191" required="">
<span class="indicator"><span class="tick"></span></span>
<span class="p3">I agree to these <a href="/en/tools/ecomm-conventional-term-and-conditions.html" target="_blank" class="lk2">Terms & Conditions</a> for credit/debit card authorisation.</span>
</label>
<div id="840236892Agree_msg" class="fieldError label-error margin-bottom-l" requiredmessage="You must agree to the Terms & Conditions."></div>
<div class="label-error agreeCredit-err-msg err"></div>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row margin-bottom-l">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p class="pre-authorise-fee-text">RM1.00 will be used as a pre-authorisation amount of your debit/credit card. The pre-authorisation amount will then be refunded to you within 14 days after the card has been
successfully added.</p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-top-md-0 margin-bottom-md-l margin-top-sm-0 margin-bottom-sm-l margin-top-0 margin-bottom-l" data-emptytext="Text">
<p> </p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
</div>
</div>
</div>
</div>
</section>
</div>
</div>
</div>
</div>
</div>
</div>
<div class=" form-page" data-form-id="3">
<div class="grid-control-1-col section">
<div class="row review-quote-details-cont">
<div class="col col-md-12 col-sm-12 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="grid-control-1-col section">
<div class="row review-quote-details-cont thank-you-cont">
<div class="col col-md-6 col-sm-10 col-xs-10 col-md-offset-3 col-sm-offset-1 col-xs-offset-1 ">
<div>
<div class="sub-title section">
<h3 class="h3 text-center p4 margin-bottom-md-l margin-bottom-sm-l margin-top-4xl margin-bottom-l">YOUR APPLICATION HAS BEEN SUBMITTED SUCCESSFULLY</h3>
</div>
<div class="text parbase section">
<div class="aia-text text-center p4 bt3 margin-bottom-xxl" data-emptytext="Text">
<p>Thank you for choosing to be an AIA Vitality member. Your membership duration is <span class="tq-free-month-text">X</span> month(s).</p>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-center p4 bt3 margin-bottom-xxl" data-emptytext="Text">
<p class="short-form-only-tq-text">Download the following mobile apps via Google Play Store or Apple App Store</p>
<p class="short-form-only-tq-text">● AIA Vitality Malaysia : For easy access to your AIA Vitality account </p>
<p class="short-form-only-tq-text">● AIA Vitality Weekly Challenge : Stay active and enjoy up to 2 rewards per month</p>
</div>
</div>
<div class="button aiabase parbase section">
<div class="margin-bottom-xxl proceed-to-login-btn">
<div>
<button id="btn2093426754" class="btn btn-default btn-primary center-block " type="button" onclick="buttonClick(this)" data-link="/content/my/en/my-aia/myaia-login.html?channel=vmp" data-target="_self">LOGIN TO AIA
VITALITY MEMBER PORTAL</button>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row review-quote-details-cont thank-you-lite-cont">
<div class="col col-md-6 col-sm-10 col-xs-10 col-md-offset-3 col-sm-offset-1 col-xs-offset-1 ">
<div>
<div class="sub-title section">
<h3 class="h3 text-center p4 margin-bottom-md-l margin-bottom-sm-l margin-top-4xl margin-bottom-l">YOUR VITALITY STARTER MEMBERSHIP HAS BEEN REGISTERED SUCCESSFULLY</h3>
</div>
<div class="text parbase section">
<div class="aia-text text-center p4 bt3 margin-bottom-xxl" data-emptytext="Text">
<p>Thank you for applying for the AIA Vitality Starter membership. You will receive a welcome email shortly.</p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="section-container section">
<section style="background-color:rgb(250,249,243);">
<div class="container ">
<div>
<div class="sub-title section">
<h4 class="h4 text-center p4 margin-bottom-md-l margin-bottom-sm-l margin-top-xl margin-bottom-l">DOWNLOAD THE ALL-NEW MY AIA APP</h4>
</div>
<div class="text parbase section">
<div class="aia-text text-center p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>For easy access to your AIA Vitality account and enjoy up to 2 rewards per month!</p>
</div>
</div>
<div class="grid-control-3-col section">
<div class="row margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-top-0 margin-bottom-0 app-banner-cont text-center">
<div class="col col-md-4 col-sm-4 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="image aiabase parbase section">
<div class="margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-bottom-l">
<img src="/content/dam/my/en/images/vitality-application-std/android-1.png" alt="The New MY AIA App">
</div>
</div>
</div>
</div>
<div class="col col-md-4 col-sm-4 col-xs-12 ">
<div>
<div class="image aiabase parbase section">
<div class="margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-bottom-l">
<img src="/content/dam/my/en/images/vitality-application-std/android-6.png" alt="Get healthier with AIA Vitality">
</div>
</div>
</div>
</div>
<div class="col col-md-4 col-sm-4 col-xs-12 ">
<div>
<div class="image aiabase parbase section">
<div class="margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-top-0 margin-bottom-0">
<img src="/content/dam/my/en/images/vitality-application-std/android-4.png" alt="Earn rewards for your healthy habits!">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<style>
.app-banner-cont {
width: 100%;
max-width: 815px;
margin: 0 auto;
}
.app-banner-cont>.col {
padding-left: 8px;
padding-right: 8px;
}
.app-banner-cont img {
width: 100%;
max-width: 261px;
}
.app-download-cont {
max-width: 976px;
margin: 0 auto 100px;
}
.app-download-cont .qr-code-img {
width: 100%;
max-width: 144px;
margin: 0 auto;
}
.app-download-cont .btn-download {
width: 100%;
max-width: 288px;
margin: 24px auto 0;
}
@media (max-width: 767px) {
.app-download-cont {
margin-bottom: 76px;
}
.app-download-cont .btn-download {
width: 70%;
margin-left: auto;
margin-right: auto;
margin-top: 0;
margin-bottom: 24px;
}
}
</style>
</div>
<div class="sub-title section">
<h4 class="h4 text-center p4 margin-top-xxl margin-bottom-3xl">DOWNLOAD THE APP VIA APPLE APP STORE OR GOOGLE PLAY STORE</h4>
</div>
<div class="grid-control-3-col section">
<div class="row margin-top-md-0 margin-bottom-md-0 margin-top-sm-0 margin-bottom-sm-0 margin-top-0 margin-bottom-0 app-download-cont text-center">
<div class="col col-md-4 col-sm-4 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="image aiabase parbase section">
<div class="margin-bottom-l qr-code-img text-center hidden-xs hidden-sm">
<img src="/content/dam/my/en/images/vitality-application-std/qr-app-store.png" alt="App Store">
</div>
</div>
<div class="image aiabase parbase section">
<div class="margin-bottom-l btn-download">
<a href="https://itunes.apple.com/my/app/my-aia/id1286476389?mt=8" target="_blank" data-target="#img2012526231">
<img src="/content/dam/my/en/images/vitality-application-std/btn-download-app-store.png" alt="App Store">
</a>
</div>
</div>
</div>
</div>
<div class="col col-md-4 col-sm-4 col-xs-12 ">
<div>
<div class="image aiabase parbase section">
<div class="margin-bottom-l qr-code-img text-center hidden-xs hidden-sm">
<img src="/content/dam/my/en/images/vitality-application-std/qr-google-play.png" alt="Google Play Qr Code">
</div>
</div>
<div class="image aiabase parbase section">
<div class="margin-bottom-l btn-download">
<a href="https://play.google.com/store/apps/details?id=com.aia.myaia" target="_blank" data-target="#img1749658838">
<img src="/content/dam/my/en/images/vitality-application-std/btn-download-google-play.png" alt="Google Play">
</a>
</div>
</div>
</div>
</div>
<div class="col col-md-4 col-sm-4 col-xs-12 ">
<div>
<div class="image aiabase parbase section">
<div class="margin-bottom-l qr-code-img text-center hidden-xs hidden-sm">
<img src="/content/dam/my/en/images/vitality-application-std/qr-app-gallery.png" alt="App Gallery Qr Code">
</div>
</div>
<div class="image aiabase parbase section">
<div class="margin-bottom-l btn-download">
<a href="https://appgallery.huawei.com/#/app/C102562515" target="_blank" data-target="#img862151508">
<img src="/content/dam/my/en/images/vitality-application-std/btn-download-app-gallery.png" alt="App Gallery">
</a>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
</div>
</div>
</div>
</div>
</div>
</div>
<div class=" form-page" data-form-id="4">
<div class="grid-control-1-col section">
<div class="row review-quote-details-cont negative-form-cont">
<div class="col col-md-6 col-sm-10 col-xs-10 col-md-offset-3 col-sm-offset-1 col-xs-offset-1 ">
<div>
<div class="sub-title section">
<h3 class="h3 p4 margin-bottom-md-l margin-bottom-sm-l margin-top-4xl margin-bottom-l">Unable to process Application</h3>
</div>
<div class="sub-title section">
<h4 class="h4 p1 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l">SORRY, YOUR APPLICATION CANNOT BE PROCESSED.</h4>
</div>
<div class="text parbase section">
<div class="aia-text p4 bt3 margin-bottom-md-l margin-bottom-sm-l margin-bottom-l" data-emptytext="Text">
<p>Please key-in the following details and we will contact you soon.</p>
</div>
</div>
<div class="text parbase section">
<label id="text-id1258045000" form-target-name="fullName" for="aia1050382840">
<div class="aia-text text-left p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Name (as per NRIC/ Passport)</p>
</div>
</label>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia1657035514" name="negativeFullName" placeholder="e.g. John Doe" required="true" re="^[a-zA-Z @/-]{1,250}$" validationtype="text">
<div class="fieldError label-error" id="aia1657035514_msg" requiredmessage="This is a required field." remessage="Full Name contains invalid characters. Valid characters are A to Z, a to z, hyphen (-), space ( ) and apostrophe (').">
</div>
</div>
<div class="text parbase section">
<label id="text-id1170095618" form-target-name="fullName" for="aia1050382840">
<div class="aia-text text-left p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">NRIC / Passport</p>
</div>
</label>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia68888337" name="negativeNricNo" placeholder="e.g. 880506013366" required="true" re="^[a-zA-Z0-9]{1,12}$" validationtype="text">
<div class="fieldError label-error" id="aia68888337_msg" requiredmessage="This is a required field." remessage="ID Number contains invalid characters. Please check."></div>
</div>
<div class="text parbase section">
<label id="text-id368029129" form-target-name="fullName" for="aia1050382840">
<div class="aia-text text-left p4 bt3 margin-top-l" data-emptytext="Text">
<p class="margin-bottom-xxs">Mobile Number</p>
</div>
</label>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia2072081725" name="negativeMobileNo" placeholder="e.g. 0123456789" required="true" re="^[0-9]{5,16}$" validationtype="text">
<div class="fieldError label-error" id="aia2072081725_msg" requiredmessage="This is a required field."
remessage="Please enter a valid phone number. The entry can only contain numbers, must have a minimum of 5 digits and should not be more than 16 digits. "></div>
</div>
<div class="html-script section">
<br>
<script>
$(function() {
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{{title}}
{{label}}
Policy Product Type
Has Promotion
Recurring Payment
No Promo Total Amount
No Promo Monthly Amount
No Promo GST Amount
No Promo Total Free Month
AIA VITALITY MEMBERSHIP APPLICATION
ARE YOU ELIGIBLE?
Please key-in the following details to verify if you are eligible to apply for
the AIA Vitality Membership.
Identification no.
NEW NRIC other
Date of birth
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Year
20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924
--------------------------------------------------------------------------------
HAVE A PROMO CODE?
Please key-in the promo code to redeem for free trial. This field is optional.
Promo Code
By clicking "CHECK MY ELIGIBILITY", you understand and agree that your
information collected above may be held and used by AIA Health Services Sdn.
Bhd. ("AHS"). For full terms and conditions, please click HERE.
Dear customers, please be informed that we will be performing major systems
upgrade from Friday, 5 May 11:00 PM(MYT) till Saturday, 6 May 3:00PM (MYT) Sorry
for the inconvenient
Check my eligibility
Trigger Invalid promo code
Trigger Eligibility Tnc Overlay
* 1
* 2
* 3
{{TITLE}}
YES! YOU ARE ELIGIBLE TO APPLY
GREAT NEWS! YOU ARE ENTITLED TO A 12-MONTH FREE AIA VITALITY MEMBERSHIP
REACTIVATE YOUR MEMBERSHIP
OOPS SORRY! YOUR AIA VITALITY MEMBERSHIP HAS EXPIRED.
CONGRATULATIONS! YOU ARE ENTITLED TO A 12-MONTH FREE AIA VITALITY MEMBERSHIP
To continue enjoying great benefits as an AIA Vitality member, you can
reactivate your membership by updating your details below and proceed with
membership fee payment. Please note that once you have successfully reactivated
your membership, your AIA Vitality Status and points will automatically reset to
Bronze and "0" points.
{{TITLE}}
Please key-in the following details:
Name (as per NRIC/ Passport)
Gender
MALE FEMALE
Mobile Number
Please Select
Email Address
Confirm Your Email Address
Address
State
Please Select
Postcode
Country
Malaysia
CREATE YOUR ONLINE PROFILE
These details will be your login information to access both the MY AIA and AIA
Vitality portals and mobile apps
User ID
Enter Your Password
Show Password
Your password must:
* •
Have at least 9 characters with no space
* •
Contain at least one uppercase letters (A-Z)
* •
Contain at least one lowercase letters (a-z)
* •
Contain at least one special characters (eg:
~!@#$%^&*_-+=`|\(){}[]:;”’<>,.?/)
* •
NOT contain your User ID
QUOTE
MEMBERSHIP FEE
{{TOTALAMOUNTWITHCURRENCY}}
--------------------------------------------------------------------------------
{{SIDETITLE}}
Membership Duration
{{membershipDuration}}
Please tick the boxes below to proceed:
I understand and agree to the AIA Vitality Membership Terms & Conditions and
Privacy Statement.
I agree that any personal information collected or held by AIA Malaysia (AIA
Malaysia refers to AIA Bhd, AIA Public Takaful Berhad, AIA General Berhad, AIA
Health Services Sdn Bhd and AIA Pension and Asset Management Sdn Bhd,) (whether
contained in this application or otherwise obtained) may be disclosed by AIA
Malaysia to any selected third party for the purposes of cross marketing, direct
marketing and data matching and to communicate with me for such purposes. I
understand that I have a right to obtain access to and to request correction of
any personal information held by AIA Malaysia concerning me. Such request can be
made to any of AIA’s Customer Service Centre.
By creating a My AIA account, I agree to AIA's Terms of Use.
* 1
* 2
* 3
{{TITLE}}
{{SUMMARYTITLETEXT}}
Please fill up the following details:
* Name (as per NRIC/ Passport)
* {{CustomerDetails.CustomerName}}
* Gender
* {{#GENDER}}{{CustomerDetails.Gender}}{{/GENDER}}
* Mobile Number
* {{CustomerDetails.MobTel}}
* Email Address
* {{CustomerDetails.Email}}
* Address
* {{CustomerDetails.Add1}} {{CustomerDetails.Add2}} {{CustomerDetails.Add3}}
{{CustomerDetails.Postcode}}, {{CustomerDetails.State}},
{{CustomerDetails.Country}}
* Username
* {{AccountRegistration.Username}}
QUOTE
MEMBERSHIP FEE
{{TOTALAMOUNTWITHCURRENCY}}
--------------------------------------------------------------------------------
{{SIDETITLE}}
Membership Duration
{{membershipDuration}}
Auto Renewal
Your registered credit/debit card will be charged on a monthly basis from month
13th onwards.
Please tick the boxes below to proceed:
I agree to these Terms & Conditions for credit/debit card authorisation.
RM1.00 will be used as a pre-authorisation amount of your debit/credit card. The
pre-authorisation amount will then be refunded to you within 14 days after the
card has been successfully added.
YOUR APPLICATION HAS BEEN SUBMITTED SUCCESSFULLY
Thank you for choosing to be an AIA Vitality member. Your membership duration is
X month(s).
Download the following mobile apps via Google Play Store or Apple App Store
● AIA Vitality Malaysia : For easy access to your AIA Vitality account
● AIA Vitality Weekly Challenge : Stay active and enjoy up to 2 rewards per
month
LOGIN TO AIA VITALITY MEMBER PORTAL
YOUR VITALITY STARTER MEMBERSHIP HAS BEEN REGISTERED SUCCESSFULLY
Thank you for applying for the AIA Vitality Starter membership. You will receive
a welcome email shortly.
DOWNLOAD THE ALL-NEW MY AIA APP
For easy access to your AIA Vitality account and enjoy up to 2 rewards per
month!
DOWNLOAD THE APP VIA APPLE APP STORE OR GOOGLE PLAY STORE
UNABLE TO PROCESS APPLICATION
SORRY, YOUR APPLICATION CANNOT BE PROCESSED.
Please key-in the following details and we will contact you soon.
Name (as per NRIC/ Passport)
NRIC / Passport
Mobile Number
*Please verify the reCAPTCHA and tick the check box before submission.
Submit
THANK YOU FOR SUBMITTING YOUR DETAILS
WE WILL CONTACT YOU SOON!
Go back to homepage
UNABLE TO PROCESS APPLICATION
YOUR AIA VITALITY MEMBERSHIP HAS BEEN SUSPENDED.
If you are an individual policy/certificate owner, please contact
customercare@aiavitality.com for further details.
If you are covered under AIA's employee benefits, please contact your respective
HR Department/HR Personnel for further details.
Go back to homepage
CONGRATULATIONS! YOU'RE ALREADY AN AIA VITALITY MEMBER.
Please proceed to the AIA Vitality page and login with your ID and password.
PLEASE PROCEED TO LOGIN
TOTAL RM {{TotalAmount}}
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AIA MALAYSIA
Menara AIA, 99, Jalan Ampang,
50450 Kuala Lumpur
AIA Bhd.
1300-88-1899
For Overseas Customers
603 2056 1111
AIA PUBLIC Takaful Bhd.
1300-88-8922
AIA General Berhad
1300-88-1899
AIA Pension and Asset Management Sdn. Bhd.
1300-22-7771
AIA Auto Assist / Roadside Assist
1-800-88-8733
WHAT MATTERS
Health & Wellness
Finance & Insurance
Video Gallery
Mental Wellbeing
Health Statistics
ABOUT US
About AIA Bhd.
About AIA PUBLIC Takaful Bhd.
About AIA General Berhad
About AIA Pension and Asset Management Sdn. Bhd.
Careers
Community & Partnership
Events & Promotions
Sitemap
This website uses cookies for the purpose of enhancing your user experience. You
can find more information on the types of cookies we collect, what we use these
for, and how to manage your cookie settings in our Cookies Policy and Privacy
Statement.
HELP & SUPPORT
Contact Us
FAQ
Important Announcement
Form Library
AIA MALAYSIA
Menara AIA, 99, Jalan Ampang,
50450 Kuala Lumpur
AIA Bhd.
1300-88-1899
For Overseas Customers
603 2056 1111
AIA PUBLIC Takaful Bhd.
1300-88-8922
AIA General Berhad
1300-88-1899
AIA Pension and Asset Management Sdn. Bhd.
1300-22-7771
AIA Roadside Assist
1-800-88-8733
www.aia.com.my/roadsideAssist
--------------------------------------------------------------------------------
Copyright © 2023 AIA Group Limited and its subsidiaries. AIA Bhd. 200701032867
(790895-D) AIA PUBLIC Takaful Bhd. 201101007816 (935955-M) AIA General Berhad
201001040438 (924363-W) AIA Pension and Asset Management Sdn. Bhd. 201201027147
(1011637-P) AIA Health Services Sdn. Bhd. 199601016211 (388561-T). All rights
reserved.
Terms of Use | Privacy Statement | Code of Conduct | Sitemap
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TERMS & CONDITIONS
By clicking "CHECK MY ELIGIBILITY", you understand and agree that your
information collected above may be held and used by AIA Health Services Sdn.
Bhd. ("AHS"):
* be disclosed to AIA Berhad., AIA PUBLIC Takaful Bhd, and AIA General Bhd
(collectively, "AIA Entities") to check your eligibility for this membership.
* conduct data matching to verify whether you have any existing policies with
the AIA Entities.
* to communicate with you for such purposes.
Please contact us at my.contact@aia.com to obtain access to and/or to request
correction of your personal information held by AHS.
OK