Sangha Medical Assistance Application Form

The information I have provided in this form is complete and accurate.

In making this application, I understand that I have a duty to take reasonable care:

(a) not to make a misrepresentation to you (which you will unwittingly transmit to the Insurer concerned), when answering any questions you ask in this for

(b) to disclose to you any matter, other than what you have asked in (a) above, (i) that the concerned Insurer may at any time ask and/or (ii) that I know to be relevant to the concerned Insurer’s decision on whether to accept the risk or not and the rates and terms to be applied. My duty to take reasonable care for (a) above shall be based on what a reasonable person in my circumstances would have known.

I understand that the concerned Insurer needs to deal with my personal data, to administer my policy and offer me insurance products and services. To achieve these purposes, I allow you to transmit to the concerned Insurer and for the latter to disclose my personal data to selected parties in or outside Malaysia, in accordance with the concerned Insurer’s Personal Data Protection Notice.

I understand that any critical illness insurance claims are subject to the coverage limit(s), terms and conditions as stipulated in the critical illness insurance policy. I irrevocably waive my rights to any compensation or indemnity whatsoever against the United Buddhist Order of Malaysia/UBOM, it's servants, agents, representatives and officers for anything whatsoever, including but not limited to the insurer’s non-acceptance of risk, voidance of contract, refusal of claims or change of terms.

Review

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