IncomeShield declaration of continued insurability form

INCOME/LHO/UW/DCI/12/2016 • of 3

NTUC Income Insurance Co-operative LimitedIncome Centre 75 Bras Basah Road Singapore 189557 Tel: 6332 1133 • Fax: 6338 1500 Email: [email protected] • Website: www.income.com.sg

Section B: Details of life to be insured

Name (as shown in BC, NRIC or FIN) BC or NRIC or FIN number Policy number

Section A: Details of applicant or policyholder

Name (as shown in NRIC or FIN) NRIC or FIN number

IncomeShield declaration of continued insurability formStatement under section 25(5) of Insurance Act, Cap. 142 (or any future amendments to it)

You must reveal all facts you know, or ought to know, which may affect the insurance cover you are applying for. Otherwise, the insurance policy may not be valid.

Section C: Claim history

Have you made or will be making any claims, including hospitalisation claims on any policy with Income or any other insurer?

NoYes (Please give details below.)

Section D: Details of changes

1. Application for new cover or changes to policy (for example, upgrading or adding of rider)

Has there been any change in the life to be insured’s health condition (for example, staying or may be staying in hospital, consulting or may be consulting a doctor, receiving or may be receiving any medication, medical treatment, investigation or surgery) from the time the application form for your policy (including all questionnaires and additional declarations made with the application) was completed?

NoYes (Please give details for example, dates, diagnosis, current health status, etc.)

Please provide a copy of your medical reports. Enclosed Not available

2. Application for reinstatement of your policy

Has there been any change in the life to be insured’s health condition (for example, staying or may be staying in hospital, consulting or may be consulting a doctor, receiving or may be receiving any medication, medical treatment, investigation or surgery) from the date your policy ended?

NoYes (Please give details for example, dates, diagnosis, current health status, etc.)


3. Additional information to your application/policy

Only copy of medical report(s) is enclosed.

The information stated below will supersede the information declared in your application for IncomeShield and/or riders. Please indicate the question number on the application form (where applicable) and give details (for example, dates, diagnosis, current health status, etc.)



Section E: Personal data collection statement

Income recognises its obligations under the Personal Data Protection Act 2012 (PDPA) which include the collection, use and disclosure of personal data for the purpose for which an individual has given consent to.

The personal data collected by Income includes all personal data provided in this form, or in any document provided, or to be provided to us by you or your insured persons or from other sources, for the purpose of this insurance application or transaction. It includes all personal data for us to evaluate or administer this application or transaction. For example, if you are applying for an insurance policy, in addition to the personal data provided in the application form, the personal data will also include any subsequent information we collect on health or financial situation, or any information that is necessary for us to decide whether to insure and on what terms to insure, such as test results, medical examination results, and health records from medical practitioners or other insurance companies.

You may not alter any of the wording in this ‘Personal data collection statement’. Any attempt to do so will be of no effect.

1. Purpose of collection

We may collect and use the personal data to:

(a) carry out identity checks;

(b) communicate on purposes relating to an application or policy;

(c) decide whether to insure or continue to insure you and your insured persons;

(d) determine and verify your creditworthiness for the financial and insurance products you apply for;

(e) provide financial advice for product recommendation based on your financial needs analysis;

(f) provide ongoing services and respond to your inquiries or instructions;

(g) make or obtain payments;

(h) investigate and settle claims;

(i) recover any debt owed to us;

(j) detect and prevent fraud, unlawful or improper activities;

(k) conduct research and statistical analysis;

(l) coach employees and monitor for quality assurance;

(m) reinsure risks and for reinsurance administration;

(n) comply with all applicable laws, including reporting to regulatory and industry entities;

(o) inform you of our philanthropic and charity initiatives, i.e. OrangeAid, including soliciting donations, acknowledging donations, and facilitating tax exemption; and

(p) provide services and respond to inquiries by employer on the application or policy. (Applicable when this insurance application or transaction is made pursuant to a group employment insurance scheme.)

2. Disclosure of personal data

We may disclose personal data belonging to you and your insured persons for the purposes set out in Section 1 above to these parties:

(a) your financial advisers;

(b) medical professionals and institutions;

(c) insurers and reinsurers;

(d) local or overseas service providers to provide us with services such as printing, mail distribution, data storage, data entry, marketing and research, disaster recovery or emergency assistance services;

(e) debt collection agencies;

(f) dispute resolution parties;

(g) parties that assist us to investigate, administer and adjudicate claims;

(h) financial institutions;

(i) credit reference agencies;

(j) industry associations;

(k) regulators, law enforcement and government agencies; and

(l) employer. (Applicable when this insurance application or transaction is made pursuant to a group employment insurance scheme.)

3. Consequence of withdrawing consent to the collection, use and disclosure of personal data

You may refuse or withdraw your consent for us to collect, use or disclose your personal data and your insured persons’ personal data by giving us reasonable notice so long as there are no legal or contractual restrictions preventing you from doing so. For example, you may withdraw your consent for your personal data to be used for marketing purposes, and this withdrawal will not affect our ability to provide you with the products and services that you asked for or have with us.

But if you withdraw your consent for us to use your personal data for your insurance matters, this will affect our ability to provide you with the products and services that you asked for or have with us, including preventing us from keeping your insurance cover in force or properly assessing and processing your claim. Withdrawing such consent will require you to surrender or terminate all your policies with us.

4. Access and correction rights

You can request access to any personal data of yours that we have, and request to know how it is being used and disclosed for the last 12 months to the extent your right is allowed by law. If we allow you access, we may charge you a reasonable fee. You also have the right to request correction of your personal data.

You may make your request to withdraw your consent, access or correct your personal data by writing to:

The Data Protection Officer, Income Centre, 75 Bras Basah Road, Singapore 189557.

Alternatively, you can email to: [email protected]


Section F: Declaration

I declare that the answers given are true, correct and complete. I accept full responsibility for them, whether written by me or by anyone else on my behalf. I have not withheld any information. I agree that this application and other written answers, statements, information or declarations I have made or which have been made on my behalf will form the basis of the contract of insurance between the policyholder and you. If anything is untrue, incorrect or incomplete, the insurance policy will not be valid.

I confirm that I understand and agree to the ‘Personal data collection statement’.

I am aware and agree that I must declare any changes to my health condition including development of such medical condition that I have made a claim with you before.

If I am reinstating my policy, I agree that notwithstanding the terms and conditions under the policy;

i) I must give you all material information about the life to be insured from the expiry date of my policy, up till the reinstatement date that may influence your decision whether to reinstate or to impose any further terms under the policy; and

ii) If I fail to give you this material information or misrepresent any such information, you may:

a. declare the policy as void from the start date of the reinstated policy;

b. end the cover for the life to be insured and not pay any benefits; or

c. add extra terms and conditions to the policy.

I am aware and agree that the terms and conditions of my reinstated policy may be different from the terms and conditions of my policy prior to the reinstatement.

I confirm that I am not an undischarged bankrupt, that no statutory demand has been served on me and no bankruptcy order has been made against me.

This application is governed by and interpreted according to the laws of the Republic of Singapore.

Warning:You must give all the facts truthfully when you make this application. You must also tell us immediately if there is any change in the state of health of the life to be insured or if the life to be insured is planning to arrange for any medical consultation, investigation or treatment before the start date of your policy or, if you are reinstating your policy, before the reinstatement date of your policy. If you fail to reveal any material information in this application, you may not receive any benefits under your policy or we may declare your policy as void or add extra terms on your policy. If you are in doubt as to whether a fact is material, you should reveal it anyway. This includes any fact which you may have given to the adviser but is not written in this application. Please check to make sure you are fully satisfied with the information in this application. You may not alter any of the wording in this proposal form. Any attempt to do so will be of no effect.

Signed in Singapore on (dd/mm/yyyy):

Signature of applicant Signature of life to be insured (16 years old and above must sign)

INCOME/LHO/UW/AMQ/05/2020 • Page 1 of 1

821/082

Details of proposer and insuredName (as shown in NRIC or FIN)

Proposer:

Insured:

NRIC number or FIN

Proposer:

Insured:

Proposal number(s)

Questions for proposer and insuredProposer Insured

1 In the last 3 months, have you:

a) tested positive for COVID-19, or

b) self-isolated with symptoms on medical advice?

If yes to Question 1(a) and/or 1(b), when was it?

Proposer:

Question Date (dd/mm/yyyy)

Insured:


Yes No Yes No

Yes No Yes No

2 In the last 1 month, have you or any of your housemates or family members who stay with you: a) been ordered to self-isolate, received a Quarantine Order (QO) or Stay-Home Notice (SHN) due to COVID-19,

or b) had a persistent cough, sore throat, fever, raised temperature or breathlessness, or been in contact with an

individual suspected or confirmed to have COVID-19?

Yes No Yes No

3 If yes to Question (1) and/or (2), have you made a full recovery and/or returned to normal activities?

If yes, when did you fully recovered and/or returned to normal activities?

Proposer:


Insured:


If no, please provide full details.

Yes No Yes No

Product Type Affinity ElderShield DPS IncomeShield Employee Benefit Life Insurance

Additional medical questionnaireStatement under Section 25(5) of the Insurance Act, Cap. 142 (or any future amendments to it)

You must reveal all facts you know, or ought to know, which may affect the insurance cover you are applying for. Otherwise, the insurance policy may not be valid.

Declaration by the proposer and insuredI declare that the answers in this form are true, correct and complete, and I have not withheld any relevant information. I accept full responsibility for them, whether written by me or by anyone else on my behalf.I acknowledge and agree that this form will constitute part of my application for life or health insurance, and will form the basis of the contract of insurance. If anything is untrue, incorrect or incomplete, the insurance policy will not be valid.I confirm that there has been no change in the insured’s health since the completion of the application and all additional declarations made in connection with the application.I confirm my consent given in the application form for collection, use and disclosure of my personal data, including, where applicable, personal data of third party, provided by me or any other source. I understand that I can refer to Income’s Privacy Policy at http://www.income.com.sg/privacy-policy for more information.

Signature of proposer

Date (dd/mm/yyyy):

Signature of insured (for age 16 and above)

Date (dd/mm/yyyy):

INCOME/FN/GIRO/09/2019 • Page 1 of 1

For completion by applicantPlease fill in all details in ink and in BLOCK letters. Please send the original form to us. We will not process your form if it is not complete or it is a photocopy, faxed or emailed form. Do not use correction fluid or tape. If you make any changes, the bank account holder must sign next to them. This application will be rejected if any of the policy information provided below is incorrect.

Date (DD/MM/YYYY):

/ /

To: Name of Bank (‘Bank’) Name of Insurance Company:NTUC INCOME INSURANCE CO-OPERATIVE LIMITED

Policy NumberFor ILP policies please select Premium or Top Up^* This column is not applicable to Customer^^

Name of Proposer/Insured as per policy record or Customer^^

ID of Proposer/Insuredas per policy record or ID of Customer^^(Last 4 characters only)

Relationship to Accountholder

1. Premium Top up

2. Premium Top up

3. Premium Top up

4. Premium Top up

5. Premium Top up

^ Top up refers to recurring top up. It is applicable for Investment-linked policy only.^^ Customer refers to the customer who engages a service provider through the referral services offered by Insurance Company.

Authorisation by Proposer/Insured/Customer^^1. I/We hereby instruct the Bank to process the above Insurance Company’s instruction to debit my/our account.2. The Bank is entitled to reject the Insurance Company’s instruction if my/our account does not have sufficient funds and charge me/us a fee for this. The Bank may also at its discretion allow the debit even if this results in an overdraft on the account and impose charges accordingly.3. This authorisation will remain in force until the Bank’s written notice sent to my/our address last known to the Bank; or upon the Bank’s receipt of my/ our written revocation; or upon the Bank’s receipt of the notice of expiry from the Insurance Company.

Bank Accountholder’s Name: Signature/Thumbprint*/Company Stamp

(As in Bank’s record)* For thumbprint, please go to any branches of your Bank with identification document for verification

Bank Accountholder’s ID:

Bank Account Number

Telephone Number (Mobile) : (Work) : (Home) :

Note:1. Please provide all information/bank account details as per the bank’s record correctly to avoid delay in approval.2. If your premium/service fee should alter due to changes in policy/service contract, the amount deducted will be changed accordingly.

GIRO application form

For financial institution’s completionTo: NTUC INCOME INSURANCE CO-OPERATIVE LIMITED 75 Bras Basah Road, Income Centre, Singapore 189557 This application is hereby REJECTED (please tick) for the following reason(s): Signature/Thumbprint# differs from financial institution’s records Wrong account number Signature/Thumbprint# incomplete/unclear# Amendment not countersigned by customer Account operated by signature/thumbprint# Others:

Name of Bank Officer Signature of Bank Officer Date (dd/mm/yyyy)# Please delete where inapplicable

For NTUC Income Insurance Co-operative Limited’s completion

SWIFT BIC NTUC Income Insurance Co-operative Limited Bank Account Number

D B S S S G S G X X X 0 0 1 0 0 1 1 2 1 9

SWIFT BIC Account Number To Be Debited

NTUC Income Insurance Co-operative Limited Customer’s Billing Reference

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IncomeShield declaration of continued insurability form

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Transcript of IncomeShield declaration of continued insurability form