I/We declare that the statement and particulars contained herein and provided to AIA Singapore Private Limited (hereinafter called "AIA Singapore") are in all respects true and complete to the best of my knowledge and belief.
I/We hereby authorise, agree and consent to AIA Singapore:
to request from any hospitals, physicians, person or organisation, all information with respect to any illness, injury, medical history and copies of all hospital or medical records concerning myself at any time and authorise the prior mentioned organisations to disclose such information 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 "AIA Persons"), to collect, use, disclose, store, retain and/or process (collectively, "Use") all personal data and information ("Personal Data") 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 ("PD Policy") which is available on AIA Singapore's website.
I/We hereby authorise, agree and consent to accept 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 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 consent shall be valid and effective as the original.
hospital and surgical
Hospitalization Admission/Consultation Date : 10 December 2014