I/We declare that the statement and particulars contained herein and provided to AIA Singapore are in all respects true and complete to the best of my knowledge and belief.
I/We undertake, if required by AIA Singapore, to procure a signed written consent by the relevant insured member, in the form prescribed by AIA Singapore, for AIA Singapore to:
request from any Third Parties all information with respect to any illness, injury, medical history and copies of all hospital or medical records concerning the relevant insured member at any time;
authorise the Third Parties to disclose all such information to AIA Singapore; and
(where the information is required by me/us) disclose all such information received from the Third Parties to me/us as the authorised representative of the policyholder.
I/We agree not to hold AIA Singapore liable or responsible for any delay or failure to process any claim under my/our Policy should such written consent be submitted late or is not forthcoming. I/We further agree to indemnify AIA Singapore from all claims, demands, actions, damages, losses, penalties, costs and expenses in relation to the use, collection, storage, disclosure or processing of information received from AIA Singapore by me/us or under my/our authority, pursuant to the insured members’ written consent.
For the purposes of the undertakings under paragraph 2 above, “Third Parties” means any persons, organisations, institutions or bodies, within or outside Singapore, including but not limited to, medical sources, hospitals, doctors, other healthcare professionals, laboratories and insurance offices, associated or related parties, independent third parties, regulators, dispute resolution centres.
I/We hereby authorise, agree and consent to AIA Singapore and its associated persons/organisations, its and their third party service providers and its and their representatives, whether within or outside Singapore (collectively "
") collecting, using, disclosing, storing, retaining and/or processing (collectively, "
") all personal data and information ("
") provided to AIA Persons or that they possess about me/us, in the manner and for the purposes described in the AIA Personal Data Policy ("
") which is available on AIA Singapore's website.
I/We accept that the provisions in the PD Policy as amended from time to time. Where Personal Data of another person is disclosed by me/us, I/we confirm that I/we have obtained the consent of the individual concerned, except to the extent such consent is not required under relevant laws to collect, use and/or disclose such Personal Data. I/We waive (on my/our own behalf and on behalf of each such other person) any right to claim against any of the AIA Persons for any Use in the nature of or for the purposes described above or in the PD Policy. I/We will indemnify AIA Persons for all losses and damages if I/we breach these provisions.
This declaration and consent shall bind my/our successors and assignees, and remains valid, notwithstanding death, irrespective of whether or not our Application/form is accepted by AIA Singapore. A photocopy of this declaration and consent shall be valid and effective as the original.
hospital and surgical
Hospitalization Admission/Consultation Date : 10 December 2014