[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 Insurance Pte. Ltd. ("Etiqa") and Etiqa reserves all rights to reject any claims, recover any and all amounts, or to impose additional charges 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.
[Declaration] I/We declare that the e-bills submitted are indeed what were received from the public healthcare institutions. Etiqa reserves the rights to request for the original bills or certified true copies and to contact the public healthcare institutions directly if needed for validation of the bill authenticity.
[Authorisation] I/We hereby consent to and authorise 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] By providing the information, I/ We consent to Etiqa and its related companies, its agents, authorised service providers and marketing partners collecting, using or disclosing and/or processing my/our personal data, for the purpose to evaluate my/our application and to provide the product and services which I/ We applying for and such other purposes as stated in Etiqa's Data Protection and Privacy Statement on Etiqa’s website, which I/ We confirmed that I/ We have read and understood.
[Customer’s Data Privacy Consent] I/ We confirm and agree that my/our consents herein supplement but do not supersede or replace any other consents which I/ We may have previously provided to Etiqa , and are additional to any rights which Etiqa may have at law to collect, use or disclose my/our personal data, with or without my/ our consent, to the extent permitted under applicable law.
[Customer’s Data Privacy Consent] In addition, where personal data of any person is disclosed by me/us, I/ We further confirm and represent that I/ We have obtained the consent of the individual concerned for the purposes, unless such consent is not required under applicable laws.
[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.