IMPORTANT NOTICE:

Statement pursuant to Section 25 (5) Cap. 142 of the Insurance Act or any subsequent amendments thereof – You are to disclose in this proposal form fully and faithfully all the facts which you know or ought to know about the risk that is being proposed, otherwise the policy issued hereunder 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 Liberty Insurance or visit the GIA or SDIC websites (www.gia.org.sg or www.sdic.org.sg).

This policy is not a Medisave-approved policy and you may not use Medisave to pay the premium for this policy. This is a short-term accident and health policy and the insurer is not required to renew this policy. The insurer may terminate this policy by giving you 30 days notice in writing.

• Coverage under this policy is limited to the following countries: Singapore, Malaysia, Thailand.
• Pre-approval is required for hospital benefits, surgery performed while a day patient in a clinic or in a physician’s office and rehabilitation treatment. See Terms and Conditions 16.1. We require pre-authorization before treatment with our call centre service in China.
• Please read and carefully complete the medical questionaire.

The following core modules form the base of your policy. Each member has the flexibility to select the cover they want.

CORE MODULES OF APPLICANT

Area of Cover

Singapore, Malaysia, Thailand

• Services rendered outside of the area of cover are covered up to SGD 65,000 per period of insurance, only if they are directly caused by sudden illness or injury occurring during the first 30 travel days of any trip outside the area of cover.
• Please refer to clause 4 of the Policy Terms and Conditions.

The following modules are optional. Each member has the flexibility to select the cover they want.

OPTIONAL CORE MODULES - APPLICANT

• Important: Available to women between 19 to 45 years of age who have selected at minimum an Extensive or Elite Hospital and Surgery on a NIL deductible basis, plus an optional Outpatient module.

PERSONAL DATA PROTECTION

I/We give consent to Liberty Insurance Pte Ltd (“Liberty”) and its employees, related companies, agents and service providers to collect, use and disclose all personal and credit card data for one or more of the purposes described in Liberty’s Data Protection Policy, including but not limited to premium payment, collection, accounting, audit, compliance, regulatory, research, analysis, verification, and dispute resolution. I/We have read and agreed to the terms of the full Policy at www.libertyinsurance.com.sg/data-protection-policy/. If any personal data furnished is not about me/us, I/we warrant that I/we have obtained consent from the data subject (or if lacking in legal capacity, his/her legal representatives, guardians or parents as the case may be) for Liberty to collect, use and disclose his/her personal data for the above  urposes and on the terms in this document, and as if the said data are about me/us. I/We warrant that all personal data I/we have provided are accurate and complete, and I/we will inform Liberty of any changes to the data as soon as practicable.

Notes: The liability of the Company (Liberty Insurance Pte Ltd) commences only when the proposal/renewal has been accepted by the Company and premium successfully deducted. Acceptance of premium does not constitute acceptance of liability

PERSONAL DATA PROTECTION STATEMENT

I give consent to Liberty Insurance Pte Ltd and third-parties including related entities, employees, agents, contractors & service-providers (collectively, “Appointees”) to collect, use and disclose all personal data relating to myself or other individuals that I have furnished via any means in the past, present & in the future, for one or more of the purposes described in Liberty’s Data Protection Policy, including but not limited to considering whether to provide insurance, carrying out due diligence, pricing, administering and servicing policies, communications, renewals, reinsurance, collections, claims, accounting, audit, legal, compliance, research, analysis, information-sharing, surveys, data storage & backups. I have read and agreed to the full Policy at www.libertyinsurance.com.sg/data-protection-policy/. If there is any personal data relating not to myself but to other individuals that I have furnished via any means in the past, present & in the future, I warrant that I have obtained prior consent from these data subjects (or if they are lacking in legal capacity, from their legal representatives, guardians or parents as the case may be) for Liberty Insurance Pte Ltd and its Appointees to collect, use and disclose their personal data for the abovementioned purposes and on the same terms herewith. I warrant that all personal data I have provided are accurate and complete, and I shall inform Liberty of any changes to the personal data to my knowledge as soon as practicable.

DECLARATION BY APPLICANT

I/We do hereby declare and warrant that:

a) All information provided by me/us in connection with this application is true, accurate and complete. I/We have not withheld any material fact and except as declared herein all persons to be insured are currently in good health to the best of my/our knowledge and belief.

b) I/We understand that any inaccurate, incomplete or false information given or any omission of information required, may at Liberty Insurance Pte Ltd’s (“Liberty”, the “Company”) discretion, render this application invalid.

c) I/We agree that this application and declaration shall be the basis of the contract between Liberty and myself.

d) I/We agree to accept the Company’s policy subject to the terms, exclusions and conditions to be expressed therein endorsed thereon or attached thereto.I understand that no insurance shall be in force until and unless the application has been accepted and the appropriate premium paid.

e) I/We agree to inform if there is any change in any of the details I have provided to Liberty in this application. I understand and agree that it is my sole responsibility to inform and update Liberty of any changes to the health or personal information of any person to be insured. I hereby agree to indemnify and absolve Liberty of any liability arising out of any use and/or disclosure by Liberty of any inaccurate or incomplete information due to my failure to update Liberty promptly of any changes to the health or personal information of any person to be insured.