UOI Personal Accident Insurance

Thank you Panel

UOI Accident Protection Insurance

Statement Pursuant to Section 25(5) of the Insurance Act, you are to disclose in this form, fully and faithfully, all the facts that you know or ought to know, otherwise this Policy issued hereunder may be void.

Your Particulars

Salutation*

Mr

Mrs

Miss

Mdm

Dr

Full Name*

Date Of Birth*

Mobile Number*

Email Address*

Passport/NRIC (Last 4 digits, e.g. 123A)

Mailing Address*

Postal Code*

Building Name

Street Name*

Block*

Storey*

Unit*

Occupation*

Indoor

Outdoor

About the Applicant

Are your occupational duties : *

Administrative

Supervisory

Manual

Is any machinery other than hand tools used in relation to your usual work?*

No

Yes

(If Yes, Please provide brief description of the incident)

Do you engage in any activities or hobbies normally regarded as dangerous?*

No

Yes

(If Yes, Please provide brief description of the incident)

Do you have any physical defect or have suffered from illness or disease or any injury during the past five years?*

No

Yes

(If Yes, Please provide brief description of the incident)

Has any insurer in connection with Accident, Sickness or Life insurance ever deferred or declined a proposal, refused renewal or terminated an insurance?*

No

Yes

(If Yes, Please provide brief description of the incident)

Has any insurer in connection with Accident, Sickness or Life insurance ever required an increased premium or imposed special conditions?*

No

Yes

(If Yes, Please provide brief description of the incident)

Do you have any Accident, Medical or Life insurance with us or any other insurance company(ies)?*

No

Yes

(If Yes, Please provide brief description of the incident)

Information on the Insurance to be taken up

Effective Date of cover

Type of Plan*

(Period of insurance is for one year)

(Annual Premium inclusive of 8% GST)

Plan 1 S$140.40

Plan 2 S$324.00

Declaration & Agreement

I understand submission of this electronic application form does not constitute to an automatic confirmation of insurance cover.

I hereby declare that the above statements and particulars are complete and correct and that no facts have been suppressed or mis-stated. I agree that this proposal shall form the basis of the contract between me and the Company.

I am aware that I can seek advice from a qualified advisor before making a commitment to purchase the product. In the event that I choose not to seek advice from a qualified adviser, I take sole responsibility to ensure that this product is appropriate to my financial needs and insurance objectives.

I acknowledge and agree that UOI may collect, use, disclose, transfer my/our personal data for the Purposes stated in UOI's Privacy Notice which can be found at www.uoi.com.sg

I further acknowledge by providing personal data relating to a third party (eg. Information of my dependent, spouse, children, parents and/or employees), I represent and warrant that the consent of that third party has been obtained for the collection, use and disclosure of the personal data for the Purposes stated in UOIýýýs Privacy Notice.

I am aware that UOI may disclose personal data collected to its third party service providers or agents (including lawyers/ law firms), which may be sited outside of Singapore, for one or more of the above Purposes, as such third party service providers or agents, if engaged by UOI, would be processing the personal data for UOI for one or more of the above Purposes. This may include disclosure to industry association.

*Mandatory information

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External Source

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