I / We confirm that I / We am the patient and the patient’s employer (respectively) and I / We declare that all the particulars given above are to the best of my / our knowledge true and correct. I / We hereby consent to and authorise the medical practitioner involved in the patient’s care to discuss and disclose treatment details, medical history and discharge arrangements with and to AXA Insurance Pte Ltd. I / We agree that a copy of this consent shall have the validity of the original. In connection with my / our claims, I / We give consent for AXA Insurance Pte Ltd(“AXA”) and their respective representatives or agents to collect, use, store, transfer and/ or disclose the information (including that provided by sources other than myself) concerning me / us, to or with all such persons (including any member of the AXA Group or any third party service provider, and whether within or outside of Singapore and related parties under this Policy) for the purpose of enabling AXA and their respective representatives or agents to provide me / us with services required of an insurance provider, including the evaluating, processing, administering and / or managing my / our claims or this Policy(ies) with AXA (as the case may be), and for the purposes set out in AXA’s Data Use Statement which can be found at http://www.axa.com.sg (“Purposes”).

I, the claimant agree to abide by the terms & conditions.