I hereby declare to PT Sompo Insurance Indonesia ("Insurer") that:
1. Regarding the Summary of Product Information:
a. I have read carefully, accepted the explanation, and understood the insurance product in accordance with the Summary of Product Information
b. I understand that the Summary of Product Information is not a part of Insurance Application and not a part of Policy
c. I understand that I have the right to ask agents / parties who cooperate with the Insurer for the distribution of insurance product / employee of the
Insurer for all matters related to the Summary of Product Information.
2. Regarding the correctness of the information I have provided related to the submission of insurance coverage, insurance coverage and insurance claim:
a. I am required to provide the correct and complete information to the Insurer
b. the information I provide to the Insurer is true to the best of My knowledge, and was made without any intent to conceal the information to the Insurer
c. I agree that if I make or in further declarations related to the process of insurance coverage and claims there are elements of forgery, fraud, silence,
incorrectly denying the facts in any way, thus the Policy or the insurance coverage shall be void and all right of indemnification under this Policy for
past or future claims will be lost
d. I agree that the information I provide will be used as a basis and an integral part of the Policy to be issued, therefore untruth information may result in
the cancellation of the insured and the rejection of any claim of indemnification by the Insurer.
3. Regarding the information and/or personal data about Me:
a. I authorize the Insurer to use and/or disclose My information and/or personal data and to verify My information and / or personal data and the information
in relation to My own condition including My illness or health to those who concerned, including but not limited to the affiliation of the Insurer, valid
service provider such as Doctors, Hospitals, and other interested party. Furthermore, this power is considered valid and has legal force
b. I agrees that the Insurer may collect and keep My information and / or personal data and the information in relation to My own condition for the purpose of providing, managing, developing and offering various insurance product owned by the Insurance to Me and purpose related to the compliance with the applicable laws
4. Regarding the insurance product, Policy and insurance coverage:
a. I understand that the requested of the insurance coverage will applies after I pay the premium to the Insurer
b. I acknowledge that before agreeing to purchase an insurance product, I am obligated to continue to read carefully, understand, and sign the Insurance
Application and Policy
c. I acknowledge and agree to abide the terms and conditions, including the exclusions which are set out in the Policy
d. I guarantee that I am in good health, free from all physical impairment/deformity upon planning for, will be and make a purchase of insurance product
e. I understand and agree that the Policy does not cover Pre-existing Medical Conditions
f. I understand that the Insurer may reject the application for the purchase of an insurance product that I submit if it does not meet the application
requirements and the regulations
g. I understand and acknowledge that some insurance products owned by Insurer are not applicable in certain areas.
5. I hereby declare that I have read, understand and agree this disclaimer and accept the terms and condition that have been set.
