1. Do you engage in any sports(s) or occupation of a dangerous or hazardous nature such as motor racing, scuba / skin diving, parachuting, military (excluding NS) or private flying other than as a fare paying passenger, etc.?
2. Has any of your application / reinstatement for life, critical illness, accident, disability income, medical insurance ever been declined, postponed, or accepted with special terms (eg: extra premium loading or exclusion imposed)?
3. a) Have you ever used addictive drugs, narcotics, glue sniffing or been treated for drug addiction?
b) Have you ever had or been treated for alcoholism?
4. Do you drink wine, beer or other alcoholic beverages?
5. Have you ever smoked cigarettes in the last 12 months?
6. a) Have you received any medical advice, counselling or treatment in connection with sexually transmitted disease, AIDS Related Complex or any other AIDS related condition.
b) Have you ever had HIV testing done? If yes, please state the reason and its results
7. In the past 3 months, have you ever had any of the following symptoms for more than one week continuously: Fatigue, weight loss, enlarged node(s) or unusual skin lesion(s)?
8. In the past 5 years, have you ever undergone or been advised to undergo any medical investigation(s) carried out on the recommendation of a doctor such as X-ray, Ultrasound, Heart scan, CT scan, Biopsy, Endoscopy, Gastroscopy, Colonoscopy, Surgical operation, etc.?
9. Have you EVER had or been told you had or been treated
for:
a) Asthma, coughing with blood, pneumonia, tuberculosis,
bronchitis, breathing discomfort or breathlessness and / or
any other lung disease / disorder?
b) Rheumatic fever, high blood pressure, heart murmur, heart attack, coronary artery disease, mitral valve prolapse, or other heart valve disorder, irregular or fast heart rate, chest discomfort or chest pain, and / or any disease or disorder of the heart or blood vessels?
c) Renal / bladder stone(s), albumin/protein in urine, blood or sugar in urine, urine infection or any other disorder of the kidney(s), bladder, urinary or genital organs?
d) Epilepsy, fits, stroke, paralysis, dementia, Parkinson's disease, multiple sclerosis, motor neurone disease, weakness of limbs, polio, fainting spells, prolonged headache, anxiety, depression, or any other nervous or mental disorder(s) or disease of the brain?
e) Diabetes, thyroid disorder(s), or any other endocrine disorder(s)
f) Gastritis, ulcer, blood in stools, fistula, hernia, irritable bowel syndrome, or any other disease / disorder of the stomach or bowel
g) Hepatitis B carrier or any form of hepatitis, jaundice, liver disorder or gall bladder disorder
h) Ear discharge, nose bleeding, double vision, impaired sight, hearing or speech, or any other disorder of the ear(s), eye(s), nose, or throat?
i) Slipped disc, back pain, gout, any form of arthritis, joint pain or deformity, and / or any disease/disorder of the muscles, spine, limbs or joints or severe injury?
j) Anaemia, any other disorders of the blood, or advised to abstrain from donating or received blood transfusion?
k) Cancer, tumour(s), cyst(s) or growth(s) of any kind?
l) Congenital anomalies, physical disability or any other illness, disorder, operations, hospital admission, accident or injury not mentioned above?
10. a) Have you ever been to any doctor for a Pap Smear (cervical smear)?
b) Have you ever had any abnormal pap smear test or been told by any doctor to have a repeat pap smear within 6 months?
c) Have you ever been found to have or are you aware of any breast cyst(s) / lump(s) / nodule(s) or any other disease or disorder of the breast(s)?
d) Have you ever suffered from irregular, painful or unusually heavy menstruation, fibroid(s), cyst(s) or any other disorder involving the female organ(s)?
11. a) Were there any complication(s) noted during any of your pregnancy such as gestational diabetes, hypertension etc.?
b) Are you currently pregnant?
Please upload the supporting documents (Medical Reports, Investigative Reports and Doctor’s Memo) if any of the above answer is “Yes”.
2) I/We hereby authorise, agree and consent to:
(a) persons and organisations, whether within or outside Singapore, including but not limited to medical sources, hospitals, doctors, other healthcare professionals, laboratories, regulator, dispute resolution centres and insurers, their associated persons/ organisations, my/our or the insured person’s employers or financial service providers, or their third party service providers or representatives (collectively “Third Parties”) disclosing and releasing to AIA Singapore Private Limited ("AIA Singapore"), its associated persons/organisations, its and their third party service providers and its and their representatives, whether within or outside Singapore (collectively “AIA Persons”), any information concerning the policy owner and the insured person(s) at any time, including all personal data and information, medical information, medical history, consultation history and notes, prescriptions, treatments, descriptions of medical services rendered, and any employment and financial information, including the taking of copies of such records (collectively “Personal Data”), relevant for the Purpose (defined below);
(b) the AIA Persons sharing the scope of sub-clause (a) above, along with any of the Personal Data, with any relevant Third Parties to procure their disclosure and release of additional relevant Personal Data for the Purpose;
(c) the AIA Persons, including their approved medical examiners or laboratories, performing any necessary medical assessments and examinations and tests to determine, assess and evaluate the health of the insured person(s);
(d) the AIA Persons collecting, using, disclosing, storing, retaining and/or processing (collectively, “Using”/“Use”) the Personal Data for the Purpose; and
(e) waive any right (on my own behalf and on behalf of the insured person(s) where applicable, in respect of which I/we represent and warrant that the insured person(s) have granted me/us authority to so waive) to bring a claim of any nature against any of the AIA Persons in respect of any above-mentioned Use and/or any Use of any Personal Data for the Purpose.
Where I/we are not the insured person, I/we represent and warrant that I/we have obtained the consent of the insured person(s), except to the extent such consent is not required under relevant laws: (i) to collect their Personal Data; (ii) to disclose their Personal Data to the AIA Persons; and (iii) for the AIA Persons and Third Parties to Use any of their Personal Data in the manner and for the purposes described in this Clause. I/We hereby agree to indemnify AIA Persons for all losses and damages that AIA Persons may suffer in the event that I/we are in breach of any representation and warranty provided by me/us herein. In this Clause, “Purpose” means any of the purposes described in the AIA Personal Data Policy, including but not limited to processing of this form, to provide subsequent advice or services to me/us or the insured person in relation to any existing or future policy/policies/programmes that I/we may hold/participate with AIA Singapore. This authorisation shall bind my/our successors and assignees, and remains valid, notwithstanding death, irrespective of whether or not my/our Application/form is accepted by AIA Singapore. A photocopy of this authorisation shall be valid and effective as the original.
3) I/We understand and agree that should a Relevant Person be found at any time to be a Prohibited Person, AIA Singapore is entitled, at its absolute discretion and without any liability to me/us, to (i) decline, block, suspend or cancel this application or any request, instruction, or transaction including any payment, transfer or receipt of money; (ii) decline to provide cover or to pay any claim or benefit under the Policy; and (iii) immediately terminate or void the Policy. AIA Singapore’s decision in exercising this right shall be final. This right may only be waived in writing; no delay or failure in exercising this right shall be deemed as a waiver of the same. “Relevant Person” includes (a) persons and entities who are the policy holders, insured persons, beneficiaries, trustees, payees, or assigns; (b) their beneficial owners or affiliates; (c) (in the case of an entity) their directors, partners, or direct / indirect shareholders or persons having executive authority, or (d) natural persons appointed to act on their behalf. “Prohibited Person” includes a person or entity that is subject to any sanction, prohibition or restriction administered by any regulatory authorities in any country or jurisdiction, such that the provision of such cover, payment of such claim or provision of such benefit may in AIA Singapore’s opinion expose it to any, or any risk of, sanction, prohibition, or restriction. As an ongoing obligation, I/we will immediately inform AIA Singapore if there are any changes to the identities, status, constitution, establishment, particulars, and identification documents of these Relevant Persons. I/we will indemnify AIA Singapore and hold it harmless from and against any and all related losses, damages, costs and/or expenses suffered and/or incurred, including but not limited to legal costs.
4) I/We further agree that this form may be signed and delivered by facsimile, electronic mail or other electronic means, including via a website or electronic portal designated by AIA Singapore. A copy of such form received via any of the above means may be stored electronically or using other means by or under the authority of AIA Singapore and such copy shall have the same legal effect and validity as if it were the original.
WARNING:
If a material fact is not disclosed in this proposal, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to the Financial Services Consultant(s)/ Insurance Representative(s) but was not included in the proposal. Please check to ensure you are fully satisfied with the information declared in this proposal. Additionally and without prejudice to the parties' rights and obligations whether under law or otherwise, you must continue to disclose any and all material facts that may arise or which have changed from the information you had provided.Important Note:
Submission of this form does not warrant any acceptance of coverage. Your applied coverage will only come into effect upon notification of acceptance from AIA Singapore after the completion of medical underwriting process. In the event if your coverage is being rejected by AIA Singapore, your coverage will be defaulted to your last accepted sum assured (if any).Declared in SINGAPORE on
Name of Member
Name of Spouse (if applicable)
