I / We hereby declare that the above statements are true to the best of our / my knowledge and belief and I / We undertake to advise Sompo Insurance Singapore Pte. Ltd. (“Sompo”) promptly of all developments in connection with the claim. I / We further authorise Sompo to treat the submission of this form as my / our making a claim under my / our policy.
I / We hereby authorize any hospital physician, other person who has attended or examined me, to furnish to Sompo, or its authorized representative, any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. A photocopy of this authorization shall be considered as effective and valid as the original.
I / We consent to receive marketing and promotional information from Sompo (e.g. via email, mail, SMS, etc). I / We understand that I / We can withdraw or manage my / our consent to receive marketing and promotional information at www.sompo.com.sg
I / We am/are aware of and agree to abide by the policy terms, conditions and exclusions and confirm that the information given in this application/form is true, accurate and complete.