Statement under section 23(5) of Insurance Act, 1966 (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. Otherwise, the insurance policy may not be valid.
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POLICYHOLDER AND INSURED DETAILS
Property Details
- I confirm that I understand and agree to the Product Summary.
- I have not withheld any relevant information relating to this application. I accept full responsibility for it.
- I understand that all pre-existing medical conditions or existing physical problems are not covered
- I have not been declined or accepted on special terms under a similar personal accident insurance in the last two years.
- I am aware that the policy can be cancelled within 14 days from receipt of policy documents and the policyholder will receive a full premium refund.
- I agree that this application and other written statements, information or declaration I have made or made on my behalf, will form the basis of the contract of insurance between me and Income.
- I acknowledge that you will not be legally responsible for any claims until Income has accepted this application and have received the premium in full.
- I am aware that I can get advice from a qualified adviser before I sign this application. If I choose not to, I take full responsibility for making sure that this product is appropriate for my financial needs and insurance aims.
- I confirm that I understand and agree to the 'Personal data use statement'.
- I agree that if I or any #Relevant Person is found to be a
+Prohibited Person:
- you are entitled not to accept this application; and
- if any policy is issued, you are entitled to end this policy, not pay any benefit or not allow any transaction, such as surrender and assignment, to be carried out under this policy. You will not refund any unutilised premium when this policy is ended.
Your decision in every respect of the above will be final.
I will inform you immediately if there is any change in my or any Relevant Person’s
identity, status or identity documents.
#Relevant Person includes insured, trustee, settlor, beneficiary, assignee, nominee, payee, mortgagee, financier of this application/policy, and in relation to an entity, its director, partner, manager, person having executive authority, authorised signatory, shareholder or beneficial owner.
+Prohibited Person means a person or entity who is, or who is ^Related to a person or entity:
- subject to laws, regulations or sanctions administered by any inter-government, government, regulatory or law enforcement authorities of any country, which will prohibit or restrict you from providing insurance or carrying out any transaction under this policy, or
- who is involved in any terrorist or illegal activities or placed on sanctions listing or issued with freezing order.
^Related includes relationships such as parent, step-parent, child, step-child, adopted child, spouse, sibling, step-sibling, adopted sibling, parent-in-law, child-in-law, sibling-in-law, cousin, uncle, aunt, grandparents, niece, nephew, grandchild, employee, employer, associate, parent company, subsidiary and shareholder.
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 have any medical consultation,
investigation or treatment before the start date of this cover. If you fail to
reveal
any material information in this application, you may not receive any benefits under
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.
It is usually not a good idea to replace an existing accident and health-insurance
policy with a new one. If you end the policy early, you may have to pay a higher
premium
or have new and extra conditions attached to your new policy. You will not get a
full
refund of premiums paid under your policy.
First-year premiums after discount (inclusive of GST)