[Declaration] I/We confirm that I am/We are the claimant and/or the Policyholder and I/We declare that all the particulars given above are to the best of my/our knowledge true and correct.

[Authorization] I / We hereby consent to and authorize the medical practitioner involved in the claimant’s care to discuss and disclose treatment details and discharge arrangements with and to HSBC Life (Singapore) Pte. Ltd. I/We agree that a copy of this consent shall have the validity of the original.

[Customer’s Data Privacy Consent] In connection with my/our and/or the claimant’s claims, I/We give consent for HSBC Life (Singapore) Pte. Ltd. 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 and/or the claimant, to or with all such persons (including any member of the HSBC Group or any third party service provider, and whether within or outside of Singapore and the Policyholder when claiming under a Group Policy) for the purpose of enabling HSBC Life and their respective representatives or agents to provide me/us and/or the claimant (where applicable) with services required of an insurance provider, including the evaluating, processing, administering and/or managing my/our and/or the claimant’s claims or the Policyholder Group Policy(ies) with HSBC Life (as the case may be), and for the purposes set out in HSBC Life’s Data Privacy Policy which can be found at insurance.hsbclife.com.sg (“Purposes”).