DECLARATION
Please read the terms and condition carefully before submitting this Declaration.
Commencement of Assurance
I understand that the assurance will not commence until the proposal has been received and officially accepted by Prudential Assurance Company Singapore (Pte) Limited (”Prudential”), premiums have been paid and an official letter indicating commencement of cover has been issued.
Information Provided to Prudential
I declare that the information given in the proposal and any information supplied to Prudential or to the medical examiner of Prudential is true and that no material facts (i.e. facts likely to influence the assessment and acceptance of the proposal) have been withheld and to the best of my knowledge and belief the information given herein is true and complete and shall be the basis of my contract with Prudential. I further acknowledge and agree that Prudential can request supporting documents in relation to the information requested in the Proposal and/or this Declaration.
Provision of Medical Information and Updating of Personal Details
(a) Medical Information
I agree and authorise:
(i) Any medical source, insurance office or organisation to release to Prudential; and
(ii) Prudential to release to any medical source or insurance office any relevant information concerning the Life to be Assured at any time, irrespective of whether the proposal is accepted by Prudential.
A photographic copy of this authorisation shall be as valid as the original.
(b) Updating of the Change of Details
I agree to inform Prudential if there is any change in the state of health, occupation, financial status or lifestyle including without limitation engagement in hazardous activities of the Life to be Assured between the date of the proposal or medical examination and the issue of my policy. Additionally, I agree to inform Prudential if I apply for additional insurance policy(ies) between the date of the proposal or medical examination and the issue of my policy. On receiving this information, Prudential is entitled to accept or reject my proposal.
Electronic Receipt of Policy Documents and Correspondences
I consent to Prudential providing me with Correspondences that are unavailable electronically in hard copy.
I agree and accept that Prudential will not be responsible for any consequences arising from my failure to (i) provide Prudential with a true, complete and accurate email address and mobile number (“Contact Details”) and/or (ii) notify Prudential of any change(s) to my Contact Details. I acknowledge and accept that my Policy Document and/ or Correspondences will be delivered via post, if my Contact Details are not provided in the proposal.
Free-Look Period
I understand that I have a period of 14 days from the date of receipt of the policy documents to review its terms and conditions. If I decide that the policy is not suitable, I may cancel the policy by making a written request to Prudential within the same 14 days review period. Prudential will refund any premiums paid, less medical fees, other expenses incurred and any outstanding amounts owing to us in connection with the policy. A premium refund formula, as determined by Prudential, is used to work out the amount to be refunded.
Deemed Delivered
I understand that the policy document and all other documents from Prudential are considered delivered and received if posted, 7 days from the date of posting to the last known address notified to Prudential.
Marketing and Sales Conducted in Singapore
I confirm that the entire marketing and selling process in respect of my proposed insurance application has been conducted in Singapore, which includes but is not limited to the following:
(a) I have received all of the insurance related marketing materials in Singapore;
(b) I have signed all the documents in respect of my proposed insurance application (including but not limited to the Proposal and this Declaration) in Singapore; and
(c) If payment of any initial premiums are required for my proposed insurance policy, I have made such payments in Singapore
Singapore Policy
I understand that the policy applied for herein shall be underwritten as a Singapore policy and be entered in the register of Singapore policies of Prudential.
Bankruptcy
I declare that I am not an undischarged bankrupt and that I have committed no act of bankruptcy within the last twelve months and that no receiving order or adjudication in bankruptcy has been made against me/ us during that period.
Breach of Applicable Local Laws
I understand that if I do not hold Singapore citizenship status, it is my sole responsibility to ensure that, by completing and submitting the proposal and this Declaration, I will not breach or violate any of the applicable local laws and regulations of the jurisdiction of the country of my nationality (the “Applicable Local Laws”). I hereby fully indemnify and hold harmless Prudential and its officers, employees and agents against all losses, damages, civil penalties and expenses (including but not limited to legal expenses on a solicitor-client basis) that may be suffered by any of them in connection with any breach or violation on my part of the Applicable Local Laws.
Authority to Collect, Use and Disclose
I expressly authorise and consent Prudential Assurance Company Singapore (Pte) Limited and its related corporations, respective representatives, agents, third party service providers, contractors and/ or appointed distribution/business partners (collectively referred to as “Prudential”) to collect, use, retain, disclose and process, at their sole discretion, any and all information relating to me, including my personal particulars, my transactions and dealings and my policy or policies of insurance with Prudential, and disclosing such information to any of the following, whether in Singapore or elsewhere for purposes stated here and in Prudential’s Privacy Notice (which is available at https://www. prudential.com.sg/Privacy-Notice):
a) Prudential’s holding companies, branches, representative offices, subsidiaries, related corporations or affiliates;
b) Any of Prudential’s contractors or third party service providers or distribution / business partners or professional advisers or agents;
c) any regulatory, supervisory or other authority, court of law, tribunal or person, in any jurisdiction, where disclosure is required by law, regulation, judgement or order of court or order of any tribunal or as a matter of practice;
d) any actual or potential assignee(s) or transferee(s) of any rights and obligations of Prudential under or relating to my policy or policies for any purpose connected with the proposed assignment or transfer; and
e) any credit bureau, insurer or financial adviser, for the purposes of providing financial advisory services, underwriting, customer servicing (which including contacting you for review of your financial and/or insurance portfolio), statistical analysis, investigation of Prudential’s representatives, monitoring undesirable sales practices, conducting customer due diligence, reporting to regulatory or supervisory authorities and for auditing.
Where any personal data (third party Personal Data) relating to another person (Individual) (e.g. insured persons, family members, and beneficiaries) is disclosed by me, I represent and warrant that I have obtained the consent of the Individual for to collect and use the third party Personal Data and to disclose the third party Personal Data to the persons enumerated above, whether in Singapore or elsewhere, for the purposes stated above and in Prudential’s Privacy Notice.
I understand that if I qualify for any reward program(s) / membership(s) under the products and/or services distributed by Prudential, I may receive regular updates from Prudential on the benefits and privileges entitled to me under such program(s) / membership(s).
I understand that I can refer to Prudential Data Privacy, which is available at https://www.prudential.com.sg/Privacy-Notice for more information on contacting Prudential for Feedback, Access, Correction and Withdrawal of using my personal data.
I understand that if I am are a European Union (“EU”) resident individual (i.e. my residential address is based in any of the EU countries), I can refer to Prudential General Data Protection Regulation (“GDPR”) Privacy Data (which is available at https://www.prudential.com.sg/GDPR-Notice) for more information on the rights available to me under the GDPR
No Tax Advice
I will obtain my own advice on the tax implications and/or any other ancillary implications in respect of the application for this policy. I acknowledge that Prudential and/or its representatives do not make any representations and cannot assume any responsibility in respect of these matters.
Other Requirements
(a) Applicable Requirements including Foreign Account Tax Compliance Act (FATCA) and OECD Common Reporting Standard for Automatic Exchange of Financial Account Information (CRS)
I acknowledge that Prudential may be obliged to comply with or choose to have regard to, observe or fulfil the laws, regulations, orders, guidelines, codes, market standards, good practices, requests, requirements, or expectations of or agreements with public, judicial, taxation, governmental and other regulatory authorities or self-regulatory bodies in various jurisdictions (the “Authorities” and each an “Authority”) as promulgated and amended from time to time (the “Applicable Requirements”). These Applicable Requirements include but are not limited to FATCA which the United States Internal Revenue Service has promulgated and the CRS. In this connection, I agree that Prudential may disclose my personal information (which shall include but are not limited to my nationality, date and place of birth, addresses, telephone numbers, tax status, tax identification numbers, tax residency changes or policy details) to any Authority and withhold payments otherwise payable to me under my policy as may be reasonably necessary to ensure Prudential’s compliance or adherence (whether voluntary otherwise) with the Applicable Requirements.
(b) Consent to Collection, Use and Disclosure in relation to Applicable Requirements
I hereby consent to Prudential’s, its officers’, employees’ and agents’, collection, use and disclosure of my particulars or any information (which shall include my nationality, date and place of birth, addresses, telephone numbers, tax status, tax identification numbers, tax residency changes or details concerning my policy) to any Authority for the purpose of compliance with or adherence (whether voluntary or otherwise) to or otherwise in connection with the Applicable Requirements (‘the Purpose”) and/or I will be deemed to so consent when I provide Prudential, its officers, employees and agents, from time to time, with my particulars or any information when having been informed herein that my particulars or any information I/we provide may be collected, used and disclosed for the Purpose. Such disclosure may be effected by Prudential directly or sent and/or disclosed through any of its Head Office(s) or other related corporations or in such manner as it deems fit. For the purposes of the foregoing and notwithstanding any other provision in the proposal, or any other agreements between us, Prudential may need me to provide further information as may be required for disclosure to any Authority and it may request that I provide the same to it within such time as may be reasonably required.
(c) Updating of Information
I agree to update Prudential in a timely manner of any change of any detail previously provided to Prudential whether at time of application or at any other times. In particular, it is very important that I notify Prudential immediately if, where I am an individual, my nationality, addresses, telephone numbers, tax status, tax identification numbers, tax residency or personal identification numbers change or if I become tax resident in more than one country, or, where we are a corporation or any other type of entity, if our registered address, address of our place of business, substantial shareholders, legal and beneficial owners or controllers (who own or control more than 25% of our shares or ownership interest or control), tax status, tax residency changes or if I become tax resident in more than one country. If any of these changes occurs or if any other information comes to light concerning such changes, Prudential may request certain documents or information from me. Such information and documents include but are not limited to duly completed and/or executed (and, if necessary, notarized) tax declarations or forms or self-certifications.
(d) Assistance to Prudential
Notwithstanding any other provision in the proposal, Declaration or any other agreements between us, I agree to provide Prudential with such assistance as may be necessary to enable it to comply with its obligations under all Applicable Requirements concerning me or my policies with Prudential.
(e) Consequences of Failure to Report Information
If I do not provide or update Prudential with the information or documents requested in a timely manner or if any information or documents provided are not up to-date, accurate or complete, I agree that some or all of the benefits under the policy of assurance may not be available to me. In particular, I consent to and agree that Prudential may, in order to ensure its ongoing compliance or adherence (whether voluntary or otherwise) with the Applicable Requirements, and to the extent permitted by law, terminate the policy and/or withhold payment of any amount due to me (or my personal representatives) under my policy as may be reasonably necessary to comply with the Applicable Requirements and/ or deduct such amount from any policy moneys payable to me and/or pay the same to any relevant Authority as the relevant Authority or Applicable Requirements may require.
(f) Account Holder
I certify that I am the Account Holder (or am authorised to sign for the Account Holder(s)) of all the accounts to which this form relates.
Prohibited Person
I understand and agree that Prudential is entitled not to accept or process the Proposal should a person connected with the proposal be found to be a Prohibited Person, meaning a person or entity (including but not limited to any director or direct/indirect shareholder or person having executive authority or natural persons appointed to act on my behalf, beneficiaries or my Beneficial Owner(s) or beneficiaries’ Beneficial Owner(s) therein) subject to any laws, regulations and/or sanctions administered by any regulatory authorities in any country, which have the effect of prohibiting Prudential from providing insurance coverage, transacting business with or otherwise offering any economic benefits to me or any other beneficiaries or assignees under the relevant Policy, and the decision of Prudential shall be final. I further agree that in the event that Prudential becomes aware that a person connected with the policy that is issued based on this application (the “relevant Policy”)
(including but not limited to any of the Assured, trustee, assignee, Beneficiary, Beneficial Owner, or nominee) is or has become a Prohibited Person, Prudential may block and/or terminate the (i) coverage of that Insured, and/or (ii) relevant Policy, with immediate effect, and shall not thereafter be required to transact any business with any person connected with the relevant Policy in connection with the relevant Policy, including but not limited to, making or receiving any payments under the relevant Policy. I also agree (as an ongoing obligation) to notify Prudential in writing immediately of any change(s) to the identities, status/constitution/establishment, particulars and identification documents of a person connected with the relevant Policy. If an application is accepted or processed by Prudential despite a person connected with the relevant Policy being a Prohibited Person, Prudential shall be entitled to block and/or terminate the relevant Policy at any time, whether with effect from inception of the relevant Policy or otherwise.
I declare that the information given in this form is complete and accurate. I shall promptly inform Prudential of changes to such natural person’s information in this form. I acknowledge and agree that if the information disclosed in this firm is incomplete and /or inaccurate, some or all of the benefits under the policy issued to the Policyholder may not be available, I further acknowledge and agree that Prudential has the right to request supporting documents in relation to the information disclosed in the form.
If a material fact is not disclosed in the proposal, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to the agent but was not included in the proposal. Please check to ensure you are fully satisfied with the information declared in the proposal.
