Statement under section 25(5) of Insurance Act, Cap. 142 (Or any future amendments to it) You must reveal all facts you know, or ought to know, which may affect the insurance cover you are applying. Otherwise, the insurance policy may not be valid.
Plan and Cover Type
POLICYHOLDER AND INSURED DETAILS
Adult 1 details (this will be the policyholder)
Future correspondence on this policy will be sent to this number.
Where the personal data of another person(s) (for example, personal data of my family, employee, payee/payer or beneficiary) is provided by me/us or from other sources to Income Parties, I/we represent and warrant that:
I/we have obtained their consent for the collection, disclosure and use of their personal data; and
I am/we are authorised to give any authorisation, approval and consent on their behalf to collect, use or disclose, their personal data,
for the purposes as set out in this Personal Data Use Statement.
For the purpose of this application and any claim in connection with my/our policy(ies) with Income, I/we also authorise, agree and consent to (whether this application or transaction is accepted or refused) the following:
The medical source, insurance office, reinsurer, or organisation to release to Income any medical or relevant information to do with me or the insured;
Income to collect from and/or disclose to any medical source, insurance office, reinsurer, or organisation any medical or relevant information to do with me or the insured; and
Income or any of its approved medical examiners or laboratories to perform the necessary medical assessment and tests for Income to underwrite and evaluate me or the insured health status or condition in relation to this application and any claim in connection with my/our policy(ies) with Income.
When submitting a claim for an insurance policy, I/we consent and agree that the personal data will also include any subsequent information collected on health or any information that is necessary for Income to decide whether to pay the claim, such as test results, medical examination results, and health records from medical sources such as medical examiners or laboratories.
Terms and conditions (Declaration and authorisation)
I have not withheld any relevant information relating to this application. I accept full responsibility for it.
I understand that all pre-existing medical conditions or existing physical problems are not covered
I have not been declined or accepted on special terms under a similar personal accident insurance in the last two years.
I am aware that the policy can be cancelled within 14 days from receipt of policy documents and the policyholder will receive a full premium refund.
I agree that this application and other written statements, information or declaration I have made or made on my behalf, will form the basis of the contract of insurance between me and Income.
I acknowledge that you will not be legally responsible for any claims until Income has accepted this application and have received the premium in full.
I am aware that I can get advice from a qualified adviser before I sign this application. If I choose not to, I take full responsibility for making sure that this product is appropriate for my financial needs and insurance aims.
I confirm that I understand and agree to the 'Personal data use statement'.
I agree that if I or any Relevant Person1 is found to be a Prohibited Person2, you are entitled not to accept this application. If any policy is issued, you can terminate or void the policy, or not make any transaction under the policy such as not pay any benefit. Your decision will be final. I will inform you immediately if there is any change in my or any Relevant Person2’s identity, status or identification documents.
You must give all the facts truthfully when you make this application. You must also tell us immediately if there is any change in the state of health of the life to be insured or if the life to be insured is planning to have any medical consultation, investigation or treatment before the start date of this cover. If you fail to reveal any material information in this application, you may not receive any benefits under your policy. If you are in doubt as to whether a fact is material, you should reveal it anyway. This includes any fact which you may have given to the adviser but is not written in this application. Please check to make sure you are fully satisfied with the information in this application.
It is usually not a good idea to replace an existing policy with a new one. If you end the policy early, you may have to pay a higher premium or have new and extra conditions attached to your new policy. You will not get a full refund of premiums paid under your policy.
1Relevant Person includes insured, trustee, assignee, beneficiary, beneficial owner or nominee and mortgagee or financier 2Prohibited Person means a person or entity who is subject to laws, regulations or sanctions administered by any governmental or regulatory authorities or law enforcement in any country, which will prohibit you from providing insurance cover or paying any benefit.
Total premium (inclusive of GST)