I want to effect the insurance specified here and declare that I:

• have a valid work pass or permit required under the Employment of Foreign Manpower Act (Cap. 91A), and have resided in Singapore for more than 183 days in the past 12 months before the application date of the Policy;
• have a valid pass or permit required under the Immigration Act (Cap. 133) that has duration longer than 90 days, and have resided in Singapore continuously for at least 90 days in the past 12 months before the application date of the Policy;
• do not have any mobility problems and physical or mental disabilities;
• agree for this Policy to be classified as a Singapore Policy for accounting purposes;
• understand and agree that no insurance is in force until this application is accepted by Chubb and a Policy is issued;
• am aware that Chubb will pay all benefits amount under my policy to my nominated beneficiary in the event of my death;
• am aware that in the event where my nominated beneficiary does not clear Chubb's sanctions checks, he/she will not be entitled for any claim payout under my policy;
• am aware that upon full payment of death benefit to my nominated beneficiary, Chubb will be released from any liability under the policy;
• am aware of and agree to abide by the Policy's terms, conditions and exclusions, as amended from time to time;
• understand that I should consider carefully if I intend to replace my existing accident & health policy with this Policy;
• am aware that I may get the advice of a qualified adviser before buying this Policy. If I choose not to do so, I have carefully considered whether this Policy is suitable for me;
• am aware that the cover under this Policy will terminate when I do not meet the eligibility of the Policy;
• have provided complete, true and accurate information on the enrolment form and that no material information has been withheld. I also agree that the information provided forms part of my contract with Chubb, and I acknowledge that Chubb relies and acts on the information provided to issue a Policy;
• give consent and authorisation to Chubb to collect, use, disclose, and/or process my personal data or information supplied to Chubb, without further notification to me, confidentially with its affiliated companies, third party service providers, business partners and/or other parties which may be sited outside of Singapore, for the purposes stated in Chubb's Purpose Statement including administering policies taken out with Chubb, handling claims and customer services. I agree that if I am submitting information relating to other individuals, I confirm they have consented to Chubb's collection, use and disclosure of their personal information as described above. A copy of Chubb's Data Protection Policy can be found www.chubb.com/sg-privacy and I am deemed to have read the same; and
• will write to Chubb's Data Protection Officer at 138 Market Street, #11-01 CapitaGreen, Singapore 048946 for any request to withdraw my consent, access to and/or correct any information supplied to Chubb and Chubb reserves the right to charge a reasonable fee to offset the administrative costs in complying with access requests.

PLEASE TAKE NOTE:

• You must fully and faithfully disclose all facts which you know or should know in respect of your application for insurance. Otherwise, the Policy may be void.
• 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 Chubb or visit the GIA/LIA or SDIC web-sites (www.gia.org.sg or www.lia.org.sg or www.sdic.org.sg)