Death Abroad Questionnaire

General Declaration

a) I/We confirm that I/we am/are legally entitled to make this claim on behalf of the deceased, and that all information provided is, to the best of my/our knowledge, true, complete and not misleading.

b) I/We agree to supply any additional evidence (e.g. death certificate, grant of probate, letters of administration, power of attorney) if required.

c) I/We understand that knowingly providing false, incomplete or misleading information may result in the claim being declined, recovered or legal action being taken against me/us.

d) I/We authorise payment of any benefit due under this policy to the person or entity named below (if different from the signatory), and confirm they are entitled to receive such payment.

Data Privacy

e) I/We authorise the Insurer, its reinsurers, claims assessors and appointed agents to obtain, store, process and share any personal data (including special categories of personal data) relating to the deceased and me/us from physicians, hospitals, employers, public authorities or any other third party as required to evaluate and administer this claim.

f) I/We acknowledge my/our rights to access, correct or erase personal data; to restrict or object to processing and to lodge a complaint with the UK ICO (www.ico.org.uk) or the Guernsey DPA (https://www.odpa.gg/)

g) I/We acknowledge that I/We have the right to access the Insurer’s Privacy Policy via their website: https://www.1edgeinsurance.gg/wpcontent/uploads/2025/04/1EDGE-Privacy-Policy.pdf and the Policy Distributor’s Privacy Policy via their website, as detailed in the Policy Schedule.

h) I/We are /am aware that data processing will be in accordance with:

the UK General Data Protection Regulation and Data Protection Act 2018;

the Data Protection (Bailiwick of Guernsey) Law, 2017; and

any applicable guidance of the UK Information Commissioner’s Office or Guernsey Data Protection Authority.

Obtain & Share Medical Information

i) I/We authorise any physician, hospital or other medical practitioner who treated the deceased to release all medical reports and records to the Insurer, its reinsurers, claims assessors and appointed agents.

j) I/We understand that the statutory rights under the Access to Medical Reports Act 1988 do not survive death, and that this authorisation is given under my/our authority as personal representative and under the Access to Health Records Act 1990 (as applicable).

By signing below, you acknowledge that you have read, understood and consent to all declarations set ou (A) - (J) above.

*If you withhold consent the Insurer may be unable to assess your claim.

• Please tick the relevant box for each item.
• All documents must be original or certified copies.
• Missing documents may delay assessment of the claim.

Please submit the completed form and supporting documents via the digital upload link provided or alternatively send them to the authorised Policy Administrator at the address given in Your Schedule. Please also keep copies for your own records.

This product is underwritten by 1Edge Insurance PCC Limited acting on behalf of its cell, 1Edge Insurance Cell 2 ("1Edge”) and is licensed to carry on international long-term insurance business by the Guernsey Financial Services Commission ("GFSC") with GFSC reference number: 2771296. Recourse in respect of liabilities owed to a creditor is restricted to the available assets of the Cell for the time being without recourse against the core assets of 1Edge (as defined in section 467 of the Companies Law) or the assets of any other protected cell of 1Edge. 1Edge’s registered address is Suite 1 North, 1st Floor, Albert House, South Esplanade, St Peter Port, Guernsey, GY1 1AJ

Eleos Life Limited (FRN: 998550) is authorised and regulated by the Financial Conduct Authority. Eleos Life Limited is a company registered in England and Wales (Company Number 14010855), with its registered office at 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ.