AIA SINGAPORE

HEALTH DECLARATION FORM

Corporate Solutions
3 Tampines Grande, AIA Tampines #07-00, Singapore 528799 Fax: (65) 6538 5603 / 6538 4340
Email: [email protected]
Pursuant to Section 25(5) of the Insurance Act and replacement thereof, you are to disclose in this form, fully & faithfully, all the facts
Important Note:
which you know, otherwise the policy issued hereunder may be void.

POLICY INFORMATION
Policy Number Name of Company
_

EMPLOYEE’S INFORMATION
Name (According to NRIC / Passport) – Please underline Surname

NRIC / Passport / FIN Number Nationality

Gender Marital Status Date of Birth Contact Number

Height cm
Male  Female  Single  Married  Day Month Year
Weight kg

Occupation

Email Address

DEPENDANT(S) PARTICULARS – (to complete only if spouse/children are covered)

Name NRIC/
Height Weight
(Full name as shown in Passport Gender Date of Birth
Relationship Nationality Occupation (cm) (kg)
NRIC/Passport) No. (M/F) (DD/MM/YYYY)

Spouse M/F

1st Child M/F

2nd Child M/F

3rd Child M/F

FAMILY HISTORY of the EMPLOYEE and DEPENDANT(S) (IF APPLICABLE)

Have any of your natural parents or sibling(s) suffered from cancer**, heart disease, stroke, high blood pressure, diabetes, kidney
disease, mental disorder, tuberculosis or any hereditary disease(s)? Please tick : Yes  or No 
IF YES, PLEASE PROVIDE DETAILS BELOW (** for Cancer, please specify type of cancer)
Name of Employee/Dependent Relationship Medical Condition (Diagnosis) Age at time Age of Death Cause of Death
(to Insured) of Diagnosis (If Deceased) (If Deceased)

____________________________________________________________________________________________________________________
Page 1 of 4 PLEASE RETURN TO UNDERWRITING SECTION CS-MU-NOV2018
 MEDICAL QUESTIONNAIRE
Complete ONLY IF to be insured
All 11 questions must be answered Employee Spouse 1st Child 2nd Child 3rd Child

1 Do you engage in any sports(s) or occupation of a Yes No Yes No Yes No Yes  No Yes No
dangerous or hazardous nature such as motor racing,
scuba/skin diving, parachuting, military (excluding NS) or
private flying other than as a fare paying passenger, etc.?

If yes, please furnish details in the box on page 4

2 Has any of your application / reinstatement for life, critical Yes No Yes No Yes No Yes  No Yes No
illness, accident, disability income, medical insurance ever
been declined, postponed, or accepted with special terms
(eg: extra premium loading or exclusion imposed)?

If yes, please furnish details in the box on page 4

3 a) Have you ever used addictive drugs, narcotics, glue Yes No Yes No Yes No Yes  No Yes No
sniffing or been treated for drug addiction?

b) Have you ever had or been treated for alcoholism? Yes No Yes No Yes No Yes  No Yes No
If yes, please furnish details in the box on page 4

4 Do you drink wine, beer or other alcoholic beverages? Yes No Yes No Yes No Yes  No Yes No
If yes, please furnish details :

a) Type of alcohol : (Beer / Wine / Others, please specify) __________ __________ __________ __________ __________

b) Frequency : (number of times per week) __________ __________ __________ __________ __________

c) Quantity : (mls / units per week) __________ __________ __________ __________ __________

5 Have you ever smoked cigarettes in the last 12 months? Yes No Yes No Yes No Yes  No Yes No
If yes, please provide details :-
a) Number of sticks per day : ____per day ____per day ____per day ____per day ____per day

6 a) Have you received any medical advice, counselling or Yes No Yes No Yes No Yes  No Yes No
treatment in connection with sexually transmitted disease,
AIDS Related Complex or any other AIDS related condition

b) Have you ever had HIV testing done? If yes, please state
Yes No Yes No Yes No Yes  No Yes No
the reason and its results.

If yes, please furnish details in the box on page 4

7 In the past 3 months, have you ever had any of the Yes No Yes No Yes No Yes  No Yes No
following symptoms for more than one week continuously:
Fatigue, weight loss, enlarged node(s) or unusual skin
lesion(s)?

If yes, please furnish details in the box on page 4

_______________________________________________
___
8 In the past 5 years, have you ever undergone or been Yes No Yes No Yes No Yes  No Yes No
advised to undergo any medical investigation(s) carried out
on the recommendation of a doctor such as X-ray,
Ultrasound, Heart scan, CT scan, Biopsy, Endoscopy,
Gastroscopy, Colonoscopy, Surgical operation, etc.?

If yes, please furnish details in the box on page 4

____________________________________________________________________________________________________________________
Page 2 of 4 PLEASE RETURN TO UNDERWRITING SECTION CS-MU-NOV2018
 MEDICAL QUESTIONNAIRE
Complete ONLY IF to be insured
All 11 questions must be answered Employee Spouse 1st Child 2nd Child 3rd Child
9 Have you EVER had or been told you had or been treated
for:
a) Asthma, coughing with blood, pneumonia, tuberculosis,  No
Yes  No
Yes Yes No Yes  No  No
Yes
bronchitis, breathing discomfort or breathlessness and/or
any other lung disease/disorder?
b) Rheumatic fever, high blood pressure, heart murmur,
heart attack, coronary artery disease, mitral valve prolapse,
 No
Yes  No
Yes Yes No Yes  No  No
Yes

or other heart valve disorder, irregular or fast heart rate,

chest discomfort or chest pain, and / or any disease or
disorder of the heart or blood vessels?
c) Renal/bladder stone(s), albumin/protein in urine, blood or  No
Yes  No
Yes Yes No Yes  No  No
Yes
sugar in urine, urine infection or any other disorder of the
kidney(s), bladder, urinary or genital organs?
d) Epilepsy, fits, stroke, paralysis, dementia, Parkinson's  No
Yes  No
Yes Yes No Yes  No  No
Yes
disease, multiple sclerosis, motor neurone disease,
weakness of limbs, polio, fainting spells, prolonged
headache, anxiety, depression, or any other nervous or
mental disorder(s) or disease of the brain?

e) Diabetes, thyroid disorder(s), or any other endocrine  No

Yes  No
Yes Yes No Yes  No  No
Yes
disorder(s)
f) Gastritis, ulcer, blood in stools, fistula, hernia,
irritable bowel syndrome, or any other disease/disorder of
 No
Yes  No
Yes Yes No Yes  No  No
Yes

the stomach or bowel

g) Hepatitis B carrier or any form of hepatitis, jaundice, liver  No
Yes  No
Yes Yes No Yes  No  No
Yes
disorder or gall bladder disorder
h) Ear discharge, nose bleeding, double vision, impaired  No
Yes  No
Yes Yes No Yes  No  No
Yes
sight, hearing or speech, or any other disorder of the ear(s),
eye(s), nose, or throat?
i) Slipped disc, back pain, gout, any form of arthritis, joint  No
Yes  No
Yes Yes No Yes  No  No
Yes
pain or deformity, and/ or any disease/disorder of the
muscles, spine, limbs or joints or severe injury?
j) Anaemia, any other disorders of the blood, or advised to  No
Yes  No
Yes Yes No Yes  No  No
Yes
abstrain from donating or received blood transfusion?
k) Cancer, tumour(s), cyst(s) or growth(s) of any kind? Yes No Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No
l) Congenital anomalies, physical disability or any other
illness, disorder, operations, hospital admission, accident or
injury not mentioned above?
If yes, please furnish details in the box on page 4

For Female Applicants only (including children age 12 year and above)
10 a) Have you ever been to any doctor for a Pap Smear
(cervical smear)? If yes, please state result :
 No
Yes  No
Yes Yes No Yes  No  No
Yes

(i) Result : (Normal / Abnormal) __________ __________ __________ __________ __________

b) Have you ever had any abnormal pap smear test or been
told by any doctor to have a repeat pap smear within 6
 No
Yes Yes  No Yes  No Yes  No Yes  No
months?
c) Have you ever been found to have or are you aware of  No
Yes Yes  No Yes  No Yes  No Yes  No
any breast cyst(s) /lump(s) /nodule(s) or any other disease
or disorder of the breast(s)?
d) Have you ever suffered from irregular, painful or  No
Yes Yes  No Yes  No Yes  No Yes  No
unusually heavy menstruation, fibroid(s), cyst(s) or any
other disorder involving the female organ(s)?
If yes, please furnish details in the box on page 4

11 a) Were there any complication(s) noted during any of your

pregnancy such as gestational diabetes, hypertension etc.?
 No
Yes  No
Yes Yes No Yes  No  No
Yes

If yes, please provide details.

__________ __________ __________ __________ __________
(i) Details :
b) Are you currently pregnant?  No
Yes  No
Yes Yes No Yes  No  No
Yes

If yes, please state weeks of pregnancy : _______ _______ _______ _______ _______
____________________________________________________________________________________________________________________
Page 3 of 4 PLEASE RETURN TO UNDERWRITING SECTION CS-MU-NOV2018
 If any of the answers is “Yes”, please give full details in the space provided below
Please provide date of consultation, details of diagnosis/exact condition,
Qn. No. Name of Insured
result, name and address of doctor seen

DECLARATIONS
1) I hereby declare and confirm that I have read and understood the contents of "Your Guide to Health Insurance" (applicable only to accident and health business), "Your Guide to Life
Insurance" and "Product Summary". (Applicable if coverage is on voluntary basis).

2) I/We hereby authorise, agree and consent to:

(a) persons and organisations, whether within or outside Singapore, including but not limited to medical sources, hospitals, doctors, other healthcare professionals, laboratories, regulator,
dispute resolution centres and insurers, their associated persons/ organisations, my/our or the insured person’s employers or financial service providers, or their third party service providers
or representatives (collectively “Third Parties”) disclosing and releasing to AIA Singapore Private Limited ("AIA Singapore"), its associated persons/organisations, its and their third party
service providers and its and their representatives, whether within or outside Singapore (collectively “AIA Persons”), any information concerning the policy owner and the insured person(s)
at any time, including all personal data and information, medical information, medical history, consultation history and notes, prescriptions, treatments, descriptions of medical services
rendered, and any employment and financial information, including the taking of copies of such records (collectively “Personal Data”), relevant for the Purpose (defined below);

(b) the AIA Persons sharing the scope of sub-clause (a) above, along with any of the Personal Data, with any relevant Third Parties to procure their disclosure and release of additional
relevant Personal Data for the Purpose;

(c) the AIA Persons, including their approved medical examiners or laboratories, performing any necessary medical assessments and examinations and tests to determine, assess and
evaluate the health of the insured person(s);

(d) the AIA Persons collecting, using, disclosing, storing, retaining and/or processing (collectively, “Using”/“Use”) the Personal Data for the Purpose; and

(e) waive any right (on my own behalf and on behalf of the insured person(s) where applicable, in respect of which I/we represent and warrant that the insured person(s) have granted me/us
authority to so waive) to bring a claim of any nature against any of the AIA Persons in respect of any above-mentioned Use and/or any Use of any Personal Data for the Purpose.

Where I/we are not the insured person, I/we represent and warrant that I/we have obtained the consent of the insured person(s), except to the extent such consent is not required under
relevant laws: (i) to collect their Personal Data; (ii) to disclose their Personal Data to the AIA Persons; and (iii) for the AIA Persons and Third Parties to Use any of their Personal Data in the
manner and for the purposes described in this Clause. I/We hereby agree to indemnify AIA Persons for all losses and damages that AIA Persons may suffer in the event that I/we are in
breach of any representation and warranty provided by me/us herein. In this Clause, “Purpose” means any of the purposes described in the AIA Personal Data Policy, including but not
limited to processing of this form, to provide subsequent advice or services to me/us or the insured person in relation to any existing or future policy/policies/programmes that I/we may
hold/participate with AIA Singapore. This authorisation shall bind my/our successors and assignees, and remains valid, notwithstanding death, irrespective of whether or not my/our
Application/form is accepted by AIA Singapore. A photocopy of this authorisation shall be valid and effective as the original.

3) I understand and agree that AIA Singapore is entitled not to accept or process this form should I or any of my dependents be found to be a Prohibited Person, meaning a person/entity
subject to any laws, regulations and/or sanctions administered by any regulatory authorities in any country , which have the effect of prohibiting AIA Singapore from providing insurance
coverage, transacting business with or otherwise offering any economic benefits to me/my dependents or any other beneficiary under the Policy , and the decision of AIA Singapore shall be
final. I/We further agree that in the event that AIA becomes aware subsequently that the Policyholder/myself/any of my dependents has become a Prohibited Person, AIA Singapore may
block and/or terminate the Policy with immediate effect, remove myself or my dependents from coverage under the Policy and shall not thereafter be required to transact any business with
the Policyholder and/or myself/my dependents in connection with the Policy, including but not limited to, making or receiving any payments under the Policy.

4) I/We further agree that this form may be signed and delivered by facsimile, electronic mail or other electronic means, including via a website or electronic portal designated by AIA
Singapore. A copy of such form received via any of the above means may be stored electronically or using other means by or under the authority of AIA Singapore and such copy shall have
the same legal effect and validity as if it were the original.

WARNING: If a material fact is not disclosed in this proposal, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are
advised to disclose it. This includes any information that you may have provided to the Financial Services Consultant(s)/ Insurance
Representative(s) but was not included in the proposal. Please check to ensure you are fully satisfied with the information declared in this
proposal. Additionally and without prejudice to the parties' rights and obligations whether under law or otherwise, you must continue to disclose
any and all material facts that may arise or which have changed from the information you had provided.

Declared in SINGAPORE on: (Day)____________________(Month)___________________(Year)

NAME & SIGNATURE OF EMPLOYEE NAME & SIGNATURE OF SPOUSE (IF APPLICABLE)

____________________________________________________________________________________________________________________
Page 4 of 4 PLEASE RETURN TO UNDERWRITING SECTION CS-MU-NOV2018