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Insurance declaration - Chubb Life

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  1. I hereby confirm that all answers in this insurance application form, including the declarations given to the examining physician, are true in all respects. I am fully aware that, if I fail to declare the truthful statements, the Company may refuse to accept my insurance application and refuse to pay any sum under the insurance policy.
  2. I and/or my legal representative allow the physician or the insurance company or hospital to other individuals who have the information about my health, disabilities, sexual behaviors, biodata, genetics, or race and/or such data of the minor in the part or in the future to disclose it to the Company or the Company’s representatives for the purpose of insurance application, consideration of insurance application or payment under the insurance policy.
  3. I and/or my legal representative allow the Company to collect, use or disclose the information about my health, disabilities, sexual behaviors, biodata, genetics, or race and/or such data of the minor to other insurance companies or reinsurance brokers, reinsurance companies, legal authorities, hospitals, physicians, healthcare providers, insurance brokers or agents for the purpose of insurance application, consideration of insurance application or payment under the insurance policy.
  4. I am fully aware that, if I withdraw my consent under Item 2 or 3 given to the Company, it might affect the consideration of insurance application, payment under the insurance policy, or provision of any services related to the insurance policy, making the Company unable to comply with the insurance policy and causing me not to be covered by the insurance policy.
  5. I am fully aware that the company may collect, use, disclose, and/or transfer my personal information, including sensitive information, for the purpose of insurance application, consideration of insurance application or payment under the insurance policy under the Company’s Privacy Policy published on www.chubb.com/th-en/footer/chubblife-privacy-notice.html and that the Company may disclose my personal information to Office of Insurance Commission (OIC) for supervision and promotion of the insurance business under the insurance law and the law on Office of Insurance Commission as published on www.oic.or.th when I disclose the personal information of other people apart from mine to the Company for the purpose of insurance application, consideration of insurance application or payment under the insurance policy,
  6. I represent and warrant that I have examined the correctness and completeness of the others’ personal information given to the Company and shall keep the Company informed in case of any change of such information (if any).
  7. I represent and warrant that I have obtained the consent or am able to reply on other legal basis to collect, use, disclose, and/or transfer the others’ personal information under the governing laws.
  8. I represent and warrant that I have notified the Company’s Privacy Policy to such other people as published on www.chubb.com/th-en/footer/chubblife-privacy-notice.html, which specifies the objectives of personal data collection, usage, disclosure, and/or transfer to Office of Insurance Commission (OIC) for supervision and promotion of the insurance business under the insurance law and the law on Office of Insurance Commission, and OIC shall collect, use, disclose, and or transfer others’ personal information under OIC’s Privacy Policy as published on www.oic.or.th.
  9. I represent and warrant that the Company and Office of Insurance Commission (OIC) may collect, use, disclose, and or transfer others’ personal information under the objectives determined in the relevant Company’s Privacy Policy and OIC’s Privacy Policy which is subject to change from time to time, as well as all objectives prescribed herein and in relation to the insurance application.