INDIVIDUAL APPLICATION HEALTH / MEDICAL DECLARATION FORM

Transcription

1 INDIVIDUAL APPLICATION HEALTH / MEDICAL DECLARATION FORM Important tice Statement pursuant to Section 25(5) of the Insurance Act (Cap. 142) (or any subsequent amendments thereof): You are to disclose in this Application Form, fully and faithfully, all the facts which you know or ought to know in respect of the risk that is being proposed. Otherwise, the Policy issued hereunder may be void. Neither this Application Form nor the brochure is a contract of insurance. However, your declarations or disclosures shall form the basis of the contract of insurance. The specific terms, conditions and exclusions applicable to this insurance are set out in the Policy, a copy of which is available upon request. SECTION 1A: INDIVIDUAL APPLICATION All fields must be completed under Section 1A Name (last): Name (first): Name (middle): ID/Passport.: Date of Birth (dd/mm/yyyy): Nationality (Country of Passport): Social Security. (If U.S. Citizen): Gender: M F Smoker: Height (cm): Weight (kg): Marital Status: Single Married Others (please specify): Occupation (specify nature of duties): Usual Country of Residence: Telephone (Home): Mobile: Residential Address: Line 1: Line 2: Line 3: Country: Mailing Address (if different from residential address) : Line 1: Line 2: Line 3: Country: (Work): Fax: City: Postal Code: City: Postal Code: SECTION 1B: DEPENDANTS TO BE ENROLLED Number of eligible dependants: Details Dependant 1 Dependant 2 Dependant 3 Dependant 4 Last Name First, Middle Name Relationship to Applicant Marital Status Citizenship ID/Passport. Date of Birth (dd/mm/yyyy) Height (cm) & Weight (kg) Gender Smoker Occupation (specify nature of duties) Country of Residence M F M F M F M F 1 of 7

2 SECTION 2: PLAN SELECTION Select your plan Inpatient Only Plan Comprehensive Plan SGD OPTION Prestige A Prestige B Prestige Plus A Prestige Plus B Prestige Plus C 1. Level of Cover Basic Advanced Basic Advanced Advanced incl. Maternity Benefit 2. Territory - Select your territory Worldwide rth America & the Caribbean Exclusion Worldwide Worldwide rth America & the Caribbean Exclusion Worldwide rth America & the Caribbean Exclusion Worldwide 3. Deductible - Select your Deductible (in SGD) NIL 1,200 3,600 6,000 NIL 1,200 3,600 6,000 NIL 1,200 3,600 6,000 NIL 1,200 3,600 6,000 NIL 1,200 3,600 6, Outpatient Coinsurance N/A N/A NIL 10% 20% NIL 10% 20% NIL 10% 20% 5. Optional Dental Benefit Dental Option Dental Option with 20% Coinsurance Dental Option Dental Option with 20% Coinsurance Dental Option Dental Option with 20% Coinsurance Dental Option Dental Option with 20% Coinsurance Dental Option Dental Option with 20% Coinsurance 2 of 7

3 SECTION 3: HEALTH / MEDICAL DECLARATION Important te about filling in this form: The answers you give to the questions contained in this Application Form will form the basis of any insurance Policy issued, and will be incorporated into the contract of insurance. It is essential that you give accurate, truthful, and complete information for all persons to be insured as inaccuracies may jeopardise coverage or invalidate a claim. MEDICAL DECLARATION should be filled by individual applicant, each and every employees and/or dependants. Kindly print as needed for all your employees and/or dependants to be insured. 1. Does the occupation of any of the persons to be insured include any activities involving offshore, underwater, underground, or manual work, or work in a remote location? If, please give details. 2. Have you or any of the persons to be insured previously applied for/been rejected for or held a PROHealth policy? If, please provide policy number. 3. Do you or any of the persons to be insured have health insurance with another company? If, please attach a copy of the policy and Benefits Schedules, and indicate if the other coverage will be continued if the PROHealth application is approved. 4. Have you or any of the persons to be insured ever had a policy or application for life, sickness, Accident Disability, critical illness or medical insurance refused, postponed, declined, withdrawn, or had any special terms (including extra premium or exclusions) imposed? If, please provide full details. 5. Have you or any of the persons to be insured experienced, been treated for, sought advice on, or had symptoms relating to any of the following conditions listed below from (a) to (q)? Please answer every question. If the answer is to any of the following, please write the medical condition and complete the relevant questionnaire where indicated. For other medical conditions, please provide details in the table on page 3. a) Cancer, leukemia, tumours, cysts or a growth of any kind? If, please complete the Tumour & Cyst Questionnaire. b) Asthma, persistent cough, coughing of blood, pneumonia, chest or breathing complaints, chronic bronchitis, chronic sinusitis, allergies, deviated nasal septum, tuberculosis, or any disease or disorder of the lungs? If, please complete the Respiratory System Questionnaire. c) Chest pain, raised blood pressure, raised cholesterol, palpitation, skipped beats, swelling of the lower extremities, heart murmur or heart condition, breathlessness, abnormal heart rate, rheumatic fever, varicose veins, or circulatory disorder? If, please complete the Cardiovascular & Cerebrovascular / Nervous System Questionnaire. d) Indigestion, gastritis, gastric or duodenal ulcer, blood in stools, fistula, hernia, haemorrhoids or any disease or recent changes in your bowel habits, unexplained weight loss, loss of apetite? If, please complete the General Medicine Questionnaire. e) Kidney stones, urinary tract infections or complaint, blood, protein or sugar in urine, or any disease or disorder of the kidney, bladder, prostate or genito-urinary tract? If, please complete the General Medicine Questionnaire. f) Jaundice, hepatitis of any form or any disease or disorder of the gall bladder, pancreas or liver? If, please complete the General Medicine Questionnaire. g) Diabetes, thyroid disorders or any other endocrine disorders? If, please complete the Diabetes / Thyroid Questionnaire. 3 of 7

4 h) Anaemia, leukemia, thalassaemia, haemophilia, or any other disease or disorder of the blood? If, please complete the General Medicine Questionnaire. i) Disease of the brain or nervous system, stroke, epilepsy, paralysis, seizures, numbness weakness of a limb or prolonged headache? If, please complete the Cardiovascular & Cerebrovascular / Nervous System Questionnaire. j) Mental health disorder, depression, anxiety, nervous condition, stress, post traumatic stress disorder, behavioural problem, alcohol or drug addiction? If, please complete the General Medicine Questionnaire. k) Back or neck pain or strain, spinal condition, sciatica, slipped disc, whiplash, gout, arthritis, bone fracture, joint injury e.g. knee, elbow, wrist, shoulder, hallux valgus (hammer toes) or any symptoms of a muscle disorder? If, please complete the Musculo-Skeletal Questionnaire. l) Malaria, dengue fever, typhoid or any other infectious disease? m) HIV, AIDS (Acquired Immuno Deficiency Syndrome), AIDS related condition or had any positive blood test for HIV (also called AIDS or HTLV-III) virus? If, please complete the General Medicine Questionnaire. n) Psoriasis, eczema, dermatitis, acne or any other skin condition? o) Ear discharge, nose bleeds, double vision, impaired sight, hearing or speech or any other disease or disorder of the ear, eye, nose or throat? p) Any other ailment, impairment, Bodily Injury, Accident, condition(s), medical investigations, or Hospital treatments not mentioned above? q) (Females only) Pregnancy or any Complications of Pregnancy, abnormal PAPS smear result or any gynaecological disorder e.g. fibroid &/or cyst of the female reproductive system? If, please complete the Gynaecological Questionnaire. If you answered to any of the above questions that did not require a Medical Questionnaire, please give details of the condition in the table below. Name Q.. Date of first consultation Details of medical condition, including nature of treatment, results and if you have fully recovered? Name & Address of doctor, Hospital or health professional consulted Do you require any follow up treatment or consultation? If so, when? (please use an extra sheet if more space is required) 4 of 7

5 6) Other than for those medical conditions mentioned from Q1 to Q5 (a-q), have you or any of the persons to be insured been admitted to Hospital for treatment or observation or undergone any surgical procedure? If, please provide full details, including the date, diagnosis and nature of treatment or surgical procedure. 7) Are you or any of the persons to be insured taking any medication or receiving any form of treatment at the present time? If, please provide the medical condition, name of medication and dosage, and/or treatment. 8) Have you or any of the persons to be insured been advised to have or intend to seek any medical advice, test, investigation, surgical procedure, hospitalisation, or treatment in the near future? If, please provide the medical condition, attending Physician and recommended treatment. 9) Please check if any family member has been diagnosed with or is suffering from any of the following: Condition Diabetes High Blood Pressure Heart Attack Stroke Blood Disorder Leukemia Kidney Disease Cancer: Specify Type Others If, please complete. Relation to You 10) Do you visit an usual doctor/personal Physician/medical centre or Hospital? If yes, please provide the following information. If no, please provide details of all medical providers, indicate reason and/or corresponding diagnosis/ medical conditions and dates of visits during the past two (2) years. Name (last): Name (first): Name (middle): Telephone (Home): (Work): Mobile: Fax: Address: Line 1: Line 2: Line 3: City: Country: Postal Code: How long has this person been under this Physician s care: Date of last attendance (dd/mm/yyyy): Reasons and Diagnosis: (please use an extra sheet if more space is required) Important tes regarding the medical questionnaires: Take te That, all information requested in this form must be completed fully and accurately. Failure to provide all information requested herein may adversely affect the acceptance of any claim(s) you may make in the future. Our acceptance of an incomplete Application Form shall not be construed howsoever as a waiver by AIG Asia Pacific Insurance Pte. Ltd. ( AIG ) of the strict requirements for full disclosure of all relevant information requested herein. This Policy is protected under the Policy Owners Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC). Coverage for your Policy is automatic and no further action is required from you. For more information on the types of benefits that are covered under the scheme as well as the limits of coverage, where applicable, please contact AIG Asia Pacific Insurance Pte. Ltd. or visit the AIG, GIA or SDIC websites ( or or 5 of 7

6 DECLARATION BY MAIN INSURED MEMBER AND CONSENT CLAUSE I/We declare that: I/We understand that all pre-existing conditions are not covered. I/We am aware that I/we can seek advice from a qualified advisor before I/we sign this proposal form. Should I/we choose not to, I/we take sole responsibility to ensure that this product is appropriate to my/our financial needs and insurance objectives. If I am/we are switching policies, I/we should consider whether this will result in any costs and whether the benefits under the new policy are more suitable for me/us. I/We hereby declare that I am/we are ordinarily resident in Singapore as defined in the First Schedule of the Insurance Act (Cap. 142). I/We understand that I/we must inform AIG immediately if any of the information that I/we have given AIG in this form changes or is no longer accurate. I/we understand and acknowledge that it is my/our duty to disclose fully and faithfully, all the facts which I/we know or ought to know in respect of this proposed insurance and to ensure that all information provided to AIG is accurate and updated. Examples of such information include, but are not limited to, a change in occupation or nature of business. I/We hereby declare that I/we have received, read and understood, or have been advised of and understand the contents of the brochure and any information materials relating to this insurance product. I agree and consent, and if I am submitting information relating to another individual, I represent and warrant that I have the authority to provide that information to AIG, 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 (whether obtained in this form or otherwise obtained) and disclose such information to the following, whether in or outside of Singapore: a) AIG s group companies; b) AIG s (or AIG s group companies ) service providers, reinsurers, agents, distributors, business partners; c) brokers, my/his/her authorized agents or representatives, legal process participants and their advisors, other financial institutions; d) governmental/regulatory authorities, industry associations, courts, other alternative dispute resolution forums, for the purposes stated in AIG s Data Privacy Policy which include: Processing, underwriting, administering and managing my/his/her relationship with AIG; Audit, compliance, investigation and inspection purposes and handling regulatory/governmental enquiries; Compliance with legal or regulatory obligations, risk management procedures and AIG internal policies Managing AIG s infrastructure and business operations; and Carrying out market research and analysis and satisfaction surveys. te: Please refer to (and if submitting information relating to another individual, refer such individual to) the full version of AIG s Data Privacy Policy found at before you provide your consent, and/or the above representation and warranty. I also consent, and if I am submitting information relating to another individual, I represent and warrant that such individual also consents, to AIG, AIGs group companies, service providers and business partners using, processing and disclosing y/his/her personal information to: a) Enroll me/him/her in contests, prize draws and similar promotions; and b) Contact me/him/her to market other insurance, and/or financial products and/or services of AIG, AIG s group companies and/or AIG s business partners. If you or such individual wishes to opt out of being enrolled in contests, prize draws and similar promotions and from receiving marketing messages, please send an SMS to in the following format optout<space>nric/fin number or call us at Alternatively, you or such individual can opt out via our website at Name of Insured Member Signature Date 6 of 7

7 PAYMENT METHOD Please select payment method and provide details, where relevant: Cheque Payment or Money Order Please make cheque/money order payable to AIG Asia Pacific Insurance Pte. Ltd. and indicate at the back of your cheque/money order PROHealth Policy, Insured Name, Identification no. or Passport no. Send cheque/money order together with this duly completed form to: AIG Asia Pacific Insurance Pte. Ltd., AIG Building, 78 Shenton Way, #07-16, Singapore Cheque Number: Bank: Credit Card Payment Authorisation I/We, the undersigned, authorize you to charge to my Credit Card as stated below for the payment of the AIG PROHealth Plan: Please select one only: Visa Card Holder s Name: Card Number: Credit Card (For 0% Interest Instalment Payment of Premium). Expiry Date: m m y y I/We, the undersigned, authorize you to charge to my Credit Card as stated below for the payment of the AIG PROHealth Plan: Please select one only: DBS POSB UOB Citibank Please select payment period: 6-monthly interest-free payment 12-monthly interest-free payment Card Holder s Name: Card Number: Expiry Date: m m y y tes for 0% Interest Instalment Payment: 1. Subject to the relevant bank s terms and conditions. Please note that administrative fees may be imposed by the relevant bank in accordance with its respective terms and conditions in the event of premature cancellation or termination of the IPP and/or credit card account. 2. 0% interest Instalment Plans are not applicable for Corporate Cards, American Express Credit Cards and DBS Black Cards. 3. If Credit Card 0% interest Instalment Payment of Premium option is chosen, cancellation can only be effected after the Policy has been in force for three (3) months. 4. 0% interest Instalment Plans are available only if premium exceeds SGD500. Declarations: 1. Where a third party s Credit Card is used, I/We declare that the card holder has authorized and consented to such use. 2. If I have opted for the 0% Interest Instalments, I agree to be bound by DBS/POSB or UOB or Citibank Terms and Conditions governing Instalment Payment Plan posted at their respective websites. Signature of Cardholder Date 1. Credit Card payment and effective date of cover is subject to Credit Card issuer s approval. 2. All charges will be made in Singapore dollars. 3. We will only accept credit cards issued in Singapore. To be completed by producer Have you obtained Health Insurance Certification? Producer Name: Producer Code: Address: Phone.: Facsimile.: Address: AIG Asia Pacific Insurance Pte. Ltd. AIG Building 78 Shenton Way #07-16 Singapore aig.apac@henner.com Web: PROHealth Plans are underwritten by AIG Asia Pacific Insurance Pte. Ltd. Co. Reg M 7 of 7

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9 Part 3 - Acknowledgement (Please tick in the appropriate box) Client s Declaration: I/We understand that the above recommendation(s) is/are based on the facts furnished in the Know Your Client Form and I/We agree with the proposed recommendation(s). I/We do not agree with the proposed recommendation(s). If I/We should decide to switch from one health insurance product to another health insurance product, I/We understand that: 1. I/We may not be insurable at standard terms, 2. I/We may have to pay a different premium, 3. Terms and conditions may differ, and 4. Pre-existing conditions may no longer be covered. l/we agree that any information collected or held by AIG Asia Pacific Insurance Pte. Ltd. ( AIG ) (whether contained in the Application or otherwise obtained) may be used and disclosed by AIG to its associated individuals/companies or its service providers or any independent third parties (within or outside Singapore) for any matters relating to this application, any policy issued and to provide advice or information concerning products and services which AIG believes may be of interest to me/us to communicate with me/us for any purpose. Statement by Insurance Advisor: The recommendations in this document are based on your personal information collected in the Know Your Client Form, the prevailing healthcare financing system and information on healthcare costs obtained from sources believed to be reliable and accurate to the best of your insurance advisor s knowledge. If there has been any change in your circumstances since you completed that Form, please notify your Insurance Advisor as it may affect the needs analysis process. The recommendations may not be appropriate in the event of a partial or inaccurate completion of the Know Your Client Form. Signature of Client (on behalf of all Applicants) Date (dd/mm/yyyy): Signature of Insurance Advisor Date (dd/mm/yyyy): For Office Use Only To be completed by a qualified staff of the Insurer or Principal Firm of the Advisor

10 BENEFIT OVERVIEW AND PRODUCT SUMMARY (SGD) Revision effective 1 st April 2018 AIG PROHealth offers a wide range of comprehensive personal and family medical insurance products. Backed by superior customer service, AIG PROHealth is your trusted health insurance partner. AIG PROHealth also offers a wide range of plans to enhance any corporate, organisation, or association employee benefits programs, with flexible structures and cost savings. PERSONAL INFORMATION Presented to (Name of Applicant): Date (dd/mm/yyyy): Presented by (Name of Advisor): Date (dd/mm/yyyy): Covered Member(s) Gender Date of Birth (dd//mm/yyyy) Signature of Applicant Signature of Insurance Advisor PLAN SELECTED Prestige A Prestige B Prestige Plus A Prestige Plus B Prestige Plus C Please note that this is not a summary of the contract of insurance and the premium is not guaranteed. AIG Asia Pacific Insurance Pte. Ltd. ( AIG ) may at its sole discretion increase the premium from time to time depending on the claims experience of this portfolio. The annual premium is based on the Insured Person s age on the first day of the Period of Insurance and the renewal premium rates are determined by AIG at the time of renewal, based on the attained age of the Insured Person. This plan is available to a person from age 16 days to 65 years, residing in Singapore. Application is subject to underwriting review and acceptance. PRODUCT INFORMATION This is a medical plan and we will pay the compensation as set out in the Benefits Schedule, including: Worldwide coverage (including incidental travels to rth America) Benefit limit of up to SGD3.8 million per for Prestige B, Prestige Plus B and Prestige Plus C plans; Up to SGD300,000 per for Prestige A and Prestige Plus A plans Range of Deductibles are available for all AIG PROHealth plans 30-Day Free Look Privilege Hospitalisation and Outpatient Surgery coverage An unmarried child below age 18 or up to 23 years (if enrolled as full-time student) may be enrolled as a Dependant Child under any plan Eligibility: The following basic eligibility rules apply for all AIG PROHealth plans: Main applicant must be between age 18 to 65 years at the time of application. Persons to be insured must be between the ages of 16 days and 65 years at the time of application. The Proposer may add his/her spouse, and any unmarried children below age 18 to the Policy. Children cannot be added to the Policy unless a parent or a legal guardian is an Insured Person. An unmarried child who is over 18 but younger than 23 years old may also be added if he/she is enrolled in full-time education. Newborn while the mother is insured under a plan with maternity benefit may be added 16 days after birth upon request. The Newborn may enjoy free cover under the same plan as the parent for the remainder of the. The application must be received by AIG within 15 days from birth to be eligible for free cover. 1 of 15

11 Benefits Overall Maximum Policy Limit (SGD) I Outpatient 1,2 Inpatient Only Plan Comprehensive Plan Prestige A Prestige B Prestige Plus A Prestige Plus B Prestige Plus C Basic Advanced Basic Advanced $300,000 / $3,800,000 / $300,000 / $3,800,000 / Advanced incl. Maternity Benefit $3,800,000 / GP and Specialist Consultation N/A N/A Sublimit up Laboratory and Diagnostic Tests N/A N/A to $6,000 / Physiotherapy as prescribed by Physician N/A N/A applicable for the Outpatient Prescription Medicine and Drugs N/A N/A benefits II Hospitalization including Outpatient Surgery 1,2 Hospital Room $350 per day $350 per day Intensive Care or Critical Care Services Prescription Medicine and Drugs Parental Accommodation Surgical Implants and Medical Appliances Physician and other Medical Specialists Fees Surgeon's Professional Fees Anesthesiologist's Professional Fees $25,000 / 30% Surgeon's Fee $25,000 / 30% Surgeon's Fee Laboratory and Diagnostic Tests III Pre-Hospitalization 2 Medical services incurred within 30 days prior to a covered confinement in a Hospital IV Post-Hospitalization 2 Follow-up treatment, including Physician visit $1,300 / $1,300 / Laboratory and Diagnostic Tests Prescription Medicine and Drugs Private Nursing V Additional Benefits 1,2 a b c d Human Organ Transplantation Oncology (Radiotherapy and Chemotherapy) Kidney Dialysis Complementary or Alternative Medicine (Acupuncturists, bone setters and TCM up to $60 per visit applicable for all plan types) N/A $300,000 Up to 28 weeks / $925,000 N/A $300,000 Up to 28 weeks / $925,000 Up to 28 weeks / $925,000 $20,000 e Hospice / Palliative Care N/A f g AIDS / HIV Dental Treatment for up to 14 days following an Accident $20,000 N/A N/A N/A $30,000 h Mental Disorder N/A $12,500 $125,000 N/A $30,000 Up to $780 / $12,500 $125,000 Up to $780 / $12,500 $125,000 $6,000 / Policy Year & $12,500 / lifetime* N/A $6,000 / Policy Year & $12,500 / lifetime* $6,000 / Policy Year & $12,500 / lifetime* i Road Ambulance to local Hospital 2 of 15

12 Inpatient Only Plan Comprehensive Plan Prestige A Prestige B Prestige Plus A Prestige Plus B Prestige Plus C Benefits Basic Advanced Basic Advanced Advanced incl. Maternity Benefit VI Chronic Condition 2 VII a b c VIII IX X a b Hospitalization treatment Applicable Sublimit: Section II Hospitalization including Outpatient Surgery GP and Specialist Consultation N/A N/A Prescription drugs N/A N/A Maternity Maternity Benefit Pre & Post-natal services, miscarriage, delivery cost including Newborn related services Congenital Conditions of the Newborn Congenital Conditions during the first 90 days from birth Free Cover for the Child Free cover for the child during the remaining period of the mother s policy (We need to be notified in writing within 15 days from birth for the child to be eligible for this benefit) Complications of Pregnancy Complications of Pregnancy requiring Hospitalization Medical Second Opinion Services Applicable Sublimit: Section II Hospitalization including Outpatient Surgery As per Outpatient benefit sublimit As per Outpatient benefit sublimit N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Applicable Sublimit: Section II - Hospitalization including Outpatient Surgery Applicable Sublimit: Section II - Hospitalization including Outpatient Surgery $12,500 / Pregnancy $12,500 / Pregnancy As per either parent s coverage whichever is lower Second Opinion for diagnosed cases N/A N/A Travel & Emergency Assistance Service Medical Assistance Benefit Emergency Medical Evacuation & Repatriation Return of Dependant Child / Children Compassionate Visit (for 1 Immediate Family Member) Repatriation of Mortal Remains Travel Assistance Services One Way Economy Air Fare Return Economy Air Fare $18,000 / One Way Economy Air Fare Return Economy Air Fare $18,000 / One Way Economy Air Fare Return Economy Air Fare $18,000 / One Way Economy Air Fare Return Economy Air Fare $18,000 / One Way Economy Air Fare Return Economy Air Fare $18,000 / Legal Referral Eligible Eligible Eligible Eligible Eligible Travel Information Eligible Eligible Eligible Eligible Eligible Global Currency and ATM Information Eligible Eligible Eligible Eligible Eligible Global Weather Information Eligible Eligible Eligible Eligible Eligible Lost Luggage / Personal Effects Assistance Eligible Eligible Eligible Eligible Eligible XI Optional Benefit 3 a Dental Routine Dental Services Major Dental Restoration Services Premium Options: 4, 5 Up to $800 / Up to $1,800 / Up to $800 / Up to $1,800 / Up to $800 / Up to $1,800 / Up to $800 / Up to $1,800 / Up to $800 / Up to $1,800 / Territory Annual Deductible Per 1 Outpatient Coinsurance 2 Dental Coinsurance 3 rth America & the Caribbean Exclusion (NAE) 6 Worldwide 7 ne $1,200 $3,600 $6,000 te: 1. Annual Deductible Option if chosen will be for both Inpatient and Outpatient benefits EXCLUDING Maternity Benefits, Travel & Emergency Assistance Services and shall apply to each Insured person. 2. Outpatient Coinsurance Option if chosen will be for Outpatient benefits only and shall apply to each Outpatient claim. 3. Dental Coinsurance Option if chosen shall apply to Major Dental Restoration Benefit only. 4. For Group Policies, the same Plan and Premium Option shall apply to all Insured Persons under the same category. 5. For Individual Policies, the same Premium Option shall apply to all Insured Persons under the same policy. 6. Except where the country is affected by embargo or sanctions, coverage will be Worldwide excluding rth America. Coverage in rth America will be limited to sudden Illnesses and Accidental Bodily Injury while travelling in rth America and the Caribbean for a maximum of 30 days per. 7. Except where the country is afected by embargo or sanctions, coverage will be anywhere in the world. Coverage under Prestige A and Prestige Plus A plan is always Worldwide. *Lifetime Limit means that in the event a benefit is paid by Us which is subject to a lifetime limit, the amount paid will be accumulated towards and deductied from the specific limit. Renewals of the Policy will be subject to the accumulated deductions against the lifetime policy limit. In the event the lifetime limit of any benefit has been reached, cover under the benefit shall be terminated. ne 10% 20% ne 20% 3 of 15

13 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Worldwide Coverage (WW) If you select Worldwide, you will enjoy coverage anywhere in the world, including the United States of America. rth America & the Caribbean Exclusion (NAE) If you select rth America & the Caribbean Exclusion coverage, coverage will be Worldwide excluding rth America & the Caribbean. Coverage in rth America & the Caribbean will be limited to sudden Illness and Accidental Bodily Injury while travelling in rth America & the Caribbean for a maximum of 30 days per. Please note that coverage under the Prestige A and Prestige Plus A is always Worldwide. Prestige A (WW) 0 1,200 3,600 6,000 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige Plus A (WW) 0 1,200 3,600 6,000 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

14 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Prestige B (NAE) 0 1,200 3,600 6,000 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige B (WW) 0 1,200 3,600 6,000 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

15 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Prestige Plus B (NAE) 0 1,200 3,600 6,000 3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige Plus B (WW) 0 1,200 3,600 6,000 3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

16 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Prestige Plus C (NAE) 0 1,200 3,600 6,000 4, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige Plus C (WW) 0 1,200 3,600 6,000 5, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

17 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Rates at 10% Coinsurance (SGD) Prestige Plus A (WW) 0 1,200 3,600 6,000 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

18 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Rates at 10% Coinsurance (SGD) Prestige Plus B (NAE) 0 1,200 3,600 6,000 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige Plus B (WW) 0 1,200 3,600 6,000 3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

19 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Rates at 10% Coinsurance (SGD) Prestige Plus C (NAE) 0 1,200 3,600 6,000 4, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige Plus C (WW) 0 1,200 3,600 6,000 5, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

20 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Rates at 20% Coinsurance (SGD) Prestige Plus A (WW) 0 1,200 3,600 6,000 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

21 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Rates at 20% Coinsurance (SGD) Prestige Plus B (NAE) 0 1,200 3,600 6,000 2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige Plus B (WW) 0 1,200 3,600 6,000 3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

22 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Rates at 20% Coinsurance (SGD) Prestige Plus C (NAE) 0 1,200 3,600 6,000 4, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Prestige Plus C (WW) 0 1,200 3,600 6,000 5, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , of 15

23 PREMIUMS (Rates based on applicable deductibles, coinsurance and age bands) Optional Dental Benefit Prestige B (NAE), Prestige Plus B (NAE) and Prestige Plus C (NAE) Premium (SGD) Co-Insurance Prestige B (NAE) Prestige Plus B (NAE) Prestige Plus C (NAE) Dental 0% Co-Insurance Dental 20% Co-Insurance Prestige A and B (WW) Co-Insurance Prestige A (WW) Premium (SGD) Prestige B (WW) Dental 0% Co-Insurance Dental 20% Co-Insurance Prestige Plus A, B and C (WW) Co-Insurance Premium (SGD) Prestige Plus A (WW) Prestige Plus B (WW) Prestige Plus C (WW) Dental 0% Co-Insurance Dental 20% Co-Insurance of 15

24 KEY PRODUCT PROVISIONS The following are key product provisions found in the Policy terms and conditions. This is only a brief summary and you are advised to refer to the terms and conditions of the Policy for details of coverage, benefits, exclusions and general conditions. Please consult your insurance advisor or AIG should you need further explanation. (a) Terms of Renewal Coverage may be renewed on the Policy Expiry Date by payment of the annual premium. Policy can be renewed for Insured Person up to age 80 years. (b) n-guaranteed Premium Premium payable for this coverage is not guaranteed. It may be increased at the sole discretion of AIG depending on the claims experience of this portfolio. (c) Qualifying Period For Sickness Cover Eligibility of benefits commences once an Insured Person has been accepted in the plan, subject to any applicable Waiting Periods. (d) Waiting Period For Maternity Cover A 12 month Waiting Period for Maternity benefits applies to Policies when two or more Insured Persons over the age of 19 are covered under the Prestige Plus C plan. A 24 month Waiting Period for Maternity benefits applies to Policies when a single Insured Person over the age of 19 is covered under the Prestige Plus C plan. (e) Dental Waiting Periods Examinations and Tooth cleaning: waiting period, Routine Dental Treatment: Three months waiting period, Major Restorative Dental Work: Six months waiting period (f) Area of Cover AIG PROHealth Plans provide you coverage in rth America & the Caribbean for treatment of sudden Illnesses and Bodily Injury suffered while in these countries for a maximum of 30 days per even where rth America is excluded from other benefit coverage. (g) Exclusions The following treatments, items, conditions, activities and their related, associated or consequential expenses are excluded from this Policy and We shall not be liable for the same: 1. Pre-existing Conditions or any related, associated or consequential Disabilities, unless disclosed to and accepted in writing by Us and explicitly stated in the Policy Schedule as being covered by this Policy. 2. Care or treatment for which payment is not required or to the extent which is payable by any other insurance or indemnity covering You including legislation or insurance coverage relating to occupational death, Bodily Injury, Illness or disease. 3. Routine medical examinations or check-ups, examinations for employment or travel, routine eye or ear examinations, vitamins, nutritional supplements, personal care items, such as special toothpastes, tooth brushes and dental floss, vaccinations, medical certificates, hearing aids, chelation therapy except for heavy metal poisoning, hydro colon therapy, growth hormones or hair restoration drugs, counselling, Custodial or Maintenance Care, rest cures, and services or treatment at home or while a bed patient at any facility that is not a Hospital unless explicitly stated in the Policy Schedule as being covered by this Policy. 4. Treatment of obesity (including morbid obesity), and any other weight control programs, photodynamic therapy, ozone therapy, chelation therapy, services or supplies, or treatment received at health spa, hydro clinic, nature care clinics or similar establishments, including rest cures and Hospitalisation for the purpose of Physiotherapy and Occupational therapy convalescence (convalescent home, convalescent Hospital), unless explicitly stated in the Policy Schedule as being covered by this Policy. 5. Dentistry (except that which is explicitly stated in the optional Dental benefits section of the Policy Schedule as being covered by this Policy), Cosmetic Treatment, and Reconstructive Surgery except for charges incurred for the prompt treatment of a Bodily Injury. In the case of Bodily Injury to teeth, the teeth repaired must have been sound and natural, the Bodily Injury must occur while the person is an Insured and the Bodily Injury must not be directly or indirectly caused by biting or chewing. 6. Illness, tests or treatment related to fertility, Assisted Conception, impotence or erectile dysfunction, sex change, contraception, contraceptive drugs even if such drugs are prescribed for other than contraceptive self-medication or any treatment that is not scientifically recognized, sterilization including any reversal of prior sterilization surgeries. 7. Congenital Conditions, unless the claim meets the criteria to be eligible for the coverage under the Maternity Benefit. Developmental Abnormalities or any voluntary termination of pregnancy or abortion performed due to psychological or social reasons, and consequences thereof. 8. Pregnancy or childbirth including pre-natal and post-natal care, unless explicitly stated under the Maternity Benefits section of the Policy Schedule as being covered by this Policy. 9. Treatment that is either not part of Western (allopathic) medicine, except where Complementary Medicine Benefits under Part 4 Section H above are explicitly stated in the Benefit Schedule as being covered by this Policy, or which is not Medically Necessary, or complications or Disabilities consequential thereupon. 10. All costs relating to human cornea, bone marrow, muscular, skeletal, or tissue transplant from a donor to a recipient and all expenses directly or indirectly related to Organ Transplantation (including conditions requiring or likely to require transplantation and post transplantation conditions) unless such expenses are explicitly stated under the Organ Transplantation Benefit Section as being covered by this Policy. 11. Tests or treatment of psychiatric, psychological, Mental Disorder, and any physiological or psychosomatic causes or manifestations thereof unless specifically stated on the Benefit Schedule as being covered by this Policy, self-inflicted Bodily Injury, suicide or attempted suicide, deliberate exposure to exceptional danger except in an effort to save human life, smoking cessation treatments, excessive consumption of alcohol or narcotics or similar drugs or agents, sleep disorders, learning difficulties, or behavioral disorders. 15 of 15

25 12. Any treatment or test in connection with Venereal Disease, Human Immunodeficiency Virus (HIV) related Illness including Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) and/or any mutation, derivation, or variation thereof unless explicitly stated under the AIDS/HIV Benefits section of the Benefit Schedule as being covered by this Policy. 13. Experimental or pioneering medical and surgery techniques except with Our prior approval in writing. 14. Services which are not recommended and prescribed by Your attending Physician except for a Medical Second Opinion prior to surgery and continuity of fees from a referring Physician after the date on which You have been referred to another Physician or Specialist. 15. Refractive defects of the eye, such as nearsightedness and astigmatism including any laser treatments, spectacles, monocles or contact lenses. 16. Charges, or portions of charges, which are not Reasonable and Customary Charges. In the case of costs arising under any legislation which seeks to increase the cost of medical treatment and services actually received, such costs which would be considered Reasonable and Customary Charges in the absence of such legislation, are included. 17. Any costs incurred for treatment outside of the or for any period for which the appropriate premium has not been paid. 18. Any expenses related to treatment performed or ordered by a non-registered practitioner not in accordance with the standard medical practice as defined in the country of treatment 19. Disabilities as a result of participation in any Professional Sport, or aviation or aeronautics other than as a fare paying passenger on a duly licensed commercial aircraft unless such participation has been prior disclosed to and accepted by Us. 20. Disabilities while serving in any branch of the military or armed forces of any country, or international authority while on duty, or participation in War, civil war, invasion, insurrection, revolution, use of military power, usurpation of government or military power, or participation in an actual or attempted riot or any loss directly or indirectly caused by or attributable to any criminal or intentional illegal act or You breaking any government laws and regulations or any known or suspected Terrorist Act. 21. Any Disability, damage or legal liability sustained directly or indirectly by You if You are a terrorist or a member of a terrorist organization, or a narcotics trafficker, or a purveyor of nuclear, chemical or biological weapons. 22. The use, release, dispersal, escape or application of pathogenic or poisonous biological or chemical materials; or nuclear materials that directly or indirectly result in nuclear reaction or radiation or radioactive contamination. 23. Any expenses related to Disability occurring while You are engaged in caving, mountaineering or rock climbing, potholing, skydiving, parachuting, bungee-jumping, ballooning, hang gliding, deep sea diving, rallying, racing of any kind in or on any motor powered device or vehicle, and any organized sports undertaken on a professional or sponsored basis, or as a result of any activity required from or on a ship or oil-rig platform, or at a similar off-shore location. 24. Hospital inpatient treatment for convalescence, rehabilitation, supervision or conditions which in the opinion of Our medical adviser(s) can be properly treated as an outpatient. 25. Transportation costs in respect of trips made specifically for the purpose of obtaining medical treatment unless in the course of an approved Emergency Medical Evacuation, and all Emergency Medical Evacuation costs not approved in advance by Us or Our appointed twenty-four (24) hour Emergency Medical Assistance Center. 26. If, by virtue of any law or regulation which is applicable to Us, Our parent company or Our ultimate controlling entity, at the inception of this Policy or at any time thereafter, providing coverage to You is or would be unlawful because it breaches an applicable embargo or sanction, We shall provide no coverage and have no liability whatsoever nor provide any defense to You or make any payment of defense costs or provide any form of security on Your behalf, to the extent that it would be in breach of such embargo or sanction. 27. The Policy will not cover any loss, Bodily Injury, damage or legal liability suffered or sustained directly or indirectly by you if you are: a) a terrorist; b) a member of a terrorist organisation; c) a narcotics trafficker; or d) a purveyor of nuclear, chemical or biological weapons. Disclosure of Distribution Costs, Charges & Expenses: You may request for information on remuneration, including any commission, fee and other benefits that your insurance advisor has received or will be receiving for providing advice on, or arranging insurance contracts or both, in respect of any Accident and Health Policy. This Policy is protected under the Policy Owners Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC). Coverage for your Policy is automatic and no further action is required from you. For more information on the types of benefits that are covered under the scheme as well as the limits of coverage, where applicable, please contact AIG Asia Pacific Insurance Pte. Ltd. or visit the AIG, GIA or SDIC websites ( or or 16 of 15