By submitting this application form, I/We, the Insured Person(s) hereby warrant and declare on the following details:

1. I am / We are not travelling contrary to the advice of a Medical Practitioner, or for the purpose of obtaining medical treatment.
2. I am / We are Singapore Citizen, Singapore Permanent Resident, Employment Pass Holder, Work Permit Holder, Student Pass Holder or Dependent Pass Holder.
3. I am / We are aware that no insurance is in force until this application form is accepted by insurer and the premium paid.
4. I am / We are aware of and agree to abide by the Policy's terms, conditions and exclusions.

1. Statement pursuant to Section 25(5) of the Insurance Act (Cap.142) or any subsequent amendments thereof. You are to disclose on this Proposal Form fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder may be void and you will receive nothing from the Policy.
2. Refund is not allowed once the Certificate or Insurance is issued.
3. Pre-existing medical conditions are not covered by the Policy.
4. Specific terms, conditions and exclusions applicable to the insurance are set out in the Policy.
5. This policy is protected under the Policy Owners' Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC). Coverage for your policy is automatic and no further action is required from you. For more information on the types of benefits that are covered under the scheme as well as the limits of coverage, where applicable, please contact your insurer or visit the GIA or SDIC websites (www.gia.org.sg or www.sdic.org.sg)

I/We expressly authorise and consent to Etiqa Insurance Pte. Ltd. (Etiqa), its officers and employees, at their sole discretion, to disclose any and all information relating to me/us, including my/our personal particulars, my/our transactions and dealings and my/our policies of insurance with Etiqa, to any of the following persons, whether in Singapore or elsewhere, for purposes reasonably required to evaluate my/our application and to provide the product or services which I/we am/are applying for (including any new policy application, renewals and/or alterations), and such other purposes as described in Etiqa's Data Protection Statement on Etiqa's website:

1. Etiqa's holding company, subsidiary, branches, representative officers, related corporations or affiliates;
2. Any of Etiqa's contractors, or third party service providers or distribution partners or professional advisers or representatives;
3. Any regulatory, supervisory or other authority, court of law, tribunal or person, in any jurisdiction, where such disclosure is required by law, regulation, judgement or order of court of order of any tribunal or as a matter of practice;
4. Any actual or potential assignee(s) or transferee(s) of any rights and obligations of Etiqa under or relating to my policy or policies for any purpose connected with the proposed assignment or transfer; and
5. Any credit bureau or insurer, for such purpose(s) that Etiqa in its reasonable opinion considers appropriate including but not limited to the purposes of underwriting, customer servicing and investigation.

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