I, hereby declare that to the best of my knowledge and belief, the above particulars as declared by me above are true and complete in every respect and are made without reservation of any kind.

I represent and warrant that I have authority to submit this claim form to AIG Asia Pacific Insurance Pte. Ltd. (“AIG”).

I agree that the acceptance of this claim form is NOT an admission of liability on the part of AIG. Any documentary proof or report required by AIG shall be furnished at the expense of the Policyholder or Claimant.

In relation to the personal information collected in this claim form, I agree and consent, I have informed the individual about the purposes for which his/her personal information is collected, used and disclosed as well as the parties to whom such personal information may be disclosed by AIG, as set out in the contents of the consent clause contained below and the individual agrees and consents, that AIG may collect, use and process my/his/her personal information as follows:

a) The personal information collected in this form (or otherwise provided during the course of the claim process, including by way of call recordings) may be collected, used and disclosed by AIG to:

i) Process and administer this insurance claim;

ii) Assess, investigate, adjust and make a decision on this claim;

iii) Administer my insurance policy (including pursuing recovery from reinsurers or other parties);

iv) Deal with disputes and complaints;

v) Respond to requests for information from public and governmental/ regulatory authorities, statutory boards and for audit, compliance, investigation and inspection purposes;

vi) Respond to requests from the policyholder;

vii) Carry out due diligence or other screening activities (including background check(s)) in accordance with legal or regulatory obligations or risk management procedures that may be required by law or that may have been put in place by AIG;

viii) Compliance with legal or regulatory obligations, risk management procedures and AIG internal policies;

ix) Manage AIG’s infrastructure and business operations; and

x) For other purposes stated in AIG’s Data Privacy Policy.

b) AIG may transfer the personal information to the following classes of persons (whether located in Singapore or elsewhere) for the purposes identified in (a) above:

i) Third parties providing services related to the administration of my policy (including reinsurers) and processing of my claim;

ii) AIG’s agents;

iii) Brokers, my authorised agents or representatives or next-of-kin;

iv) The policyholder;

v) Legal process participants and their advisors;

vi) Governmental/regulatory authorities, industry associations, courts, other alternative dispute resolution forums;

vii) Other financial institutions for the purpose of administering this claim, obtaining policy payments;

viii) Loss adjusters, assessors, third party administrators, emergency providers, legal services providers, retailers, medical providers and travel carriers, external auditors;

ix) Another member of the AIG group (for all of the purposes stated in (a)) in any country; or

x) Other parties referred to in AIG’s Data Privacy Policy for the purposes stated therein.

Note: The full version of AIG’s Data Privacy Policy can be found at www.aig.com.sg/privacy