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IMPORTANT NOTICE:
In relation to insurance contracts wholly unrelated to your trade, business or profession
TAKE NOTE that you are under a duty to take reasonable care not to make any misrepresentation when:
(a) answering specific questions that are relevant to the decision of the insurer whether to accept the risk or not and the rates and terms to be
applied; and
(b) confirming or amending any matter previously disclosed by you in relation to your insurance contract.
Your duty of disclosure shall continue until the time the contract is entered into, varied or renewed.
In relation to insurance contracts related to your trade, business or profession
TAKE NOTE that you are under a duty to disclose to the insurer any matter that:
(a) you know to be relevant to the decision of the insurer on whether to accept the risk or not and the rates and terms to be applied; or
(b) a reasonable person in the circumstances could be expected to know to be relevant.
This duty of disclosure shall continue until the time the contract is entered into, varied or renewed.
If you do not understand your obligations as stated above, please seek clarification.
If you are in any doubt about whether certain facts are material, these facts should be disclosed.
(b) any disease or disorder of the cervix uteri, uterus or ovaries including ovarian cysts, abnormal uterine or vaginal bleeding, abnormal
enlargement of the abdomen, fibroid, polyp, carcinoma in situ, cancer and growth? If Yes, please give details.
Yes No
2. Have you undergone or been advised to have a pap smear, mammogram, biopsy or operation of the breast, ultrasound of the breasts or pelvis,
cone biopsy or colposcopy, or any other gynaecological investigations? If "Yes", please give details.
Yes No
3. Have you ever had any complications during pregnancy, such as ectopic pregnancy, pre-eclampsia, diabetes, hypertension or protein in urine?
If "Yes", please give details.
Yes No
4. Have your children ever suffered from disorder such as spina bifida, Down's Syndrome or any congenital heart disease?
If "Yes", please give details.
Yes No
It is hereby declared I have not withheld any material information that may influence the assessment or acceptance of the proposal. Without limiting
the generality of the foregoing, I hereby further declare that the answer(s) I have given above is/are true, complete and accurate.
I agree that this form will constitute the basis of my Proposal for Assurance and that failure to disclose any material fact known to me may invalidate
the contract.
Date / /
Day Month Year
NRIC No.