[Declaration] I/We declare that the information given in this form is true and correct to the best of my knowledge and belief. I/We understand that all information and supporting documents may be subject to review by Etiqa and Etiqa shall reserves all rights to recover any and all amounts if for any reason any claim is found to be fraudulent. Etiqa shall also reserve the right to pursue any actions at law or in equity that it deems appropriate in dealing with such fraudulent activity.

[Authorization] I/We hereby consent to and authorize the medical practitioner involved in the claimant’s care to discuss and disclose treatment details and discharge arrangements with and to Etiqa Insurance Pte Ltd. I/We agree that a copy of this consent shall have the validity of the original.

[Customer’s Data Privacy Consent] I/We further declared that the information written in this claim form or held by Etiqa Insurance Pte Ltd whether contained in my/our insurance application or otherwise obtained may be used and disclosed to your authorised staff, associated individuals and/or companies or any independent third parties (within or outside Singapore) who will provide claims administrative, advice and/or information or claims services in relation to my/our claim. I/We understand my/our data that may also be used for audit, business analysis and reinsurance purposes.

[Direct Credit] I/We confirm that there had not been any change to my tax residency status or any circumstances which affects my/our tax residency status and undertake to provide Etiqa with a suitably updated self-certification and documentation otherwise.

[Direct Credit] Confirm that the payment information provided by me/us in this form is true and correct and undertake to immediately inform the Company of any change in the same and will not hold the Company liable in the event that any payment transaction into my Account is delayed or cannot be effected due to incorrect or incomplete information being provided in this form, and/or for any other reason beyond the reasonable control of the Company.

[Direct Credit] Notwithstanding the above, Etiqa Insurance Pte Ltd reserves the right to release payment to me/us by cheque if we are unable to payout the claim by direct credit.