APPLICATION FOR MINDEF & MHA GROUP INSURANCE

GROUP POLICY NO. G007500 (FOR MINDEF PERSONNEL)

WARNING: PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT (CAP.142), YOU ARE TO DISCLOSE IN THIS APPLICATION FORM FULLY
AND FAITHFULLY ALL THE FACTS YOU KNOW OR OUGHT TO KNOW; OTHERWISE THE INSURANCE EFFECTED MAY BE VOID.
A. Status of Person to be insured (Tick where appropriate)
Member Regular (Includes DXOs and MEs) NSF SAF Volunteer Corps Public Officer working in MINDEF NSman*
* Your eligibility to apply for coverage under this scheme as an NSman will depend on the statutory age of your NS liability
i. Specialist rank and below: 90 days from age 40
ii. Officers and key appointment holders: 90 days from age 50
Affiliate Member DSTA/DSTA - affiliated entities employee MINDEF - related organisations employee
Dependant Spouse Child (Please use a separate application form for each insured member)
If the applicant is a dependant, please complete the NRIC No. of the Insured Serviceman:

B. Particulars of Person Applying for Insurance (Please complete in FULL and BLOCK letters)
NRIC/Birth Certificate No. Date of Birth (dd/mm/yy) Gender Male Female
Name
Nationality Contact no.
Mailing
Address
S
Residential Address
(if different from
mailing address) S
Email Occupation
Employer Nature of Job Duties

C. To be completed by Regular or NSF. Date of Enlistment/Employment

D. Please put a tick below to indicate your choice of policy(ies) and sum assured. For other preferred sum assured, please use the box(es) provided.
Type of Sum Assured (S$)
Insurance Policy 100,000 200,000 300,000 350,000 600,000 800,000 1,000,000
Group Term Life1 Other Sum Assured [ (S$) 0,000 ]
Main

Group Personal Accident1 Other Sum Assured [ (S$) 0,000 ]

2
Group Living Care (Severe CI) Other Sum Assured [ (S$) 0,000 ]
Riders

Group Living Care Plus (Early CI)2 Other Sum Assured [ (S$) 0,000 ]
Group Disability Income Sum Assured is based on 12 times 50% of the monthly salary. Regulars to submit latest pay slip. Non Regulars to submit latest pay slip or 3 years IRAS statement.
Outpatient Medicare3 To apply for Outpatient Medicare, get the form from www.aviva.com.sg or email MINDEF_insurance@aviva-asia.com

1. Application for coverage under Group Term Life and Group Personal Accident may be made independently of each other.
No medical checkup and underwriting required for up to first $250,000 Term Life and $600,000 Personal Accident. Riders are applicable for members insured with or applying for the Group Term Life
or Group Personal Accident main policy, and must not exceed the higher value of either main plan.
2. Living care covers for Critical Illness (CI) diagnosed during severe stage and Living Care Plus covers for CI diagnosed during early stage. For more information, please refer to the product summary.
3. Outpatient Medicare (OPMC): Insured needs to have a main plan (Term life or PA) / Main assured needs to sign up for OPMC before dependant can sign up for it.

E. Health Questionnaire
Height m Weight kg
Have you smoked in the last 12 months? No Yes No. of Years No. of cigarettes per day
Do you consume alcohol? No Yes (If ÔYesÕ, please state the type, quantity and frequency.)
Type of alcohol Quantity Frequency (per week)
If you are unsure whether any information is material or not, you are advised to disclose it. Yes No
1. Have you ever had or been told to have or been treated for:
a) epilepsy, stroke, neurological disorders, disorders of the eyes, ears, nose or throat, asthma, blood pressure problem, heart disorders, diabetes,
high cholesterol, thyroid disorders, hepatitis, liver disorders, bladder disorders, intestinal or bowel disorders, blood or protein in urine,
kidney disorders, prostate disorders or genito-urinary disorders, cancer, tumours, cysts or growths of any kind, slipped disc, gout, arthritis, disorders
of the muscles, spine, limbs or joints, depression, anxiety, mental or nervous disorders, anaemia or any other disorders of the blood,
AIDS, HIV or venereal disease, drug addiction, alcoholism or any other illness, physical injuries or abnormalities not listed above?
b) For Female Applicant only:
breast lumps, fibroadenoma, cysts, fibroids, ovarian cysts, endometriosis, adenomyosis or any disorders of the female reproductive system?
2. Have you ever been admitted to any hospital and/or had any surgery, accident, illness or injury in the last 5 years?
3. Have you ever been recommended by a doctor to receive any medical treatment, undergo any medical tests, investigations (excluding voluntary
health check-up) or any intention to consult any doctor for any reason, seek further treatment or alternative medicine?
4. Have you ever been consulted by any specialist/doctor and/or investigations done and/or prescriptions provided for any drugs or medications
for any medical conditions other than common illness e.g. Flu, Cough, etc?
5. Have you ever engaged in activities that will increase the likelihood of exposure to any immunity disorder such as AIDS or AIDS-related conditions
or in the last 3 months had experienced the following symptoms for more than one week continuously: fatigue, weight loss, diarrhoea or unusual
skin lesions?
6. Have you ever engaged in hazardous activity such as aviation (other than as a private paying passenger), scuba diving, motor racing, mountaineering
etc? (SAF occupations and training are exempted.)
7. Have you ever been rejected or accepted at special terms for any application, renewal or reinstatement of life, health or any other insurance policies?
(continue next page)
E. Health Questionnaire (continued)
Sub Qn Date
Details of Diagnosis / Treatment / Operation Name & Address of Doctor / Hospital
(eg. 1a, 2) From To

PERSONAL DATA CONSENT

¥ I/We agree to be contacted by Aviva (and/or Aviva group of companies or their service providers) for special marketing offers, promotions, information
about AvivaÕs products and services which may be of interest.
Please tick to provide your consent:
By Telephone Call By SMS By Mail E-Mail
I/We consent to the collection, use and disclosure of my/our personal data by Aviva and Aviva group of companies for the above purpose.
Note: This is for Insured Member only, not applicable to Dependant(s). If you are an existing Insured Member, we will update your preference
accordingly if you tick one or more of the above options. Your preference in record will remain unchanged if you do not tick any option.
¥ On behalf of myself and all proposed insured lives, I/We consent to Aviva (and Aviva related group of companies) collecting, using and/or disclosing
my/our personal data (whether contained in this form or from other sources; existing data in our record or to be collected in future) to issue and
administer my existing and/or new cover(s), policy(ies) and/or account(s) with Aviva, including the processing of my/our personal data for underwriting
purposes, payment of premiums and/or claims purposes; for statistical, research, compliance, audit and regulatory purposes; to provide general
information on product enhancements and services relevant to my needs, cover(s) or policies (including increasing benefits, adding riders/supplements
and/or insured lives) as well as to provide financial advice or product recommendations to me, where applicable.
¥ On behalf of myself and all proposed insured lives, I/We consent to Aviva (and Aviva related group of companies) collecting, using and/or disclosing
my/our personal data to enrol me/us in membership, promotional, discount or rewards programs relating to the policy.
¥ On behalf of myself and all proposed insured lives, I/We also consent to Aviva (and Aviva related group of companies) transferring my/our personal
data to Aviva related group of companies and/or third party service providers, reinsurers, suppliers or intermediaries, whether located in Singapore
or elsewhere, for the above purposes.
¥ On behalf of myself and all proposed insured lives, I/We consent to Aviva disclosing and transferring my/our personal data to a new insurer selected
by MINDEF for the purpose of facilitating and/or administering insurance coverage with the new insurer.
¥ For more information on AvivaÕs data protection policy and full details of the purposes of collection, use and disclosure of your personal data, please
visit http://www.aviva.com.sg/pdpa.html.

DECLARATION

¥ I declare that the information given above is true and complete to the best of my knowledge and understand that any misrepresentation or concealment
of facts shall render the policy to be issued null and void. I agree that this application shall be the basis of the contract of insurance to be issued
under the said Group Insurance Policy. I understand that the insurance shall not become effective until it is accepted and confirmed in writing by
Aviva Ltd.
¥ I agree to inform Aviva Ltd if there is any change in the state of my and/or my dependant(s)Õs health or my/or my dependant(s)Õs activities between
the date of this Health Declaration and the date full insurance coverage is provided by Aviva Ltd to me and my/or my dependant(s). I understand
that the terms of accepting me and or my dependant(s) as a risk for insurance coverage may vary according to such information received.
¥ I consent to Aviva Ltd seeking information from my doctor who has attended to me or from other insurance company to which I have at any time
made a proposal for insurance and I authorise the giving of such information. I further authorise Aviva Ltd to give such information obtained or
information contained herein for the purpose of obtaining insurance cover under the said Group Policy to the insurance intermediary/administrator
of the said Group Insurance Policy.
¥ For Regular servicemen/NSF: By signing the application form, I consent to MINDEF or its appointed agency/administrator releasing my personal
particulars and bank information to Aviva Ltd to update my insurance record.
¥ I hereby consent to the use of my bank accountÕs information with DBS Bank or POSB, provided by MINDEF/SAF or its appointed agency/administrator,
to Aviva Ltd for my interbank GIRO application of such group insurance schemes to DBS Bank or POSB (where applicable). However, should I choose
to use another bank account to pay for my policy(ies), I shall inform Aviva Ltd accordingly and put up the necessary GIRO application form.
¥ I acknowledge that I have access to and have read and understood the Product Summary(ies), Your Guide to Life Insurance and Your Guide to Health
Insurance together with Infographic ÒEvaluating My Health Insurance CoverageÓ May 2016 (if applicable).
¥ I am aware that I can seek advice from a qualified financial adviser representative before I sign on this application form. Should I choose not to, I take
sole responsibility to ensure that this product is appropriate to meet my financial needs and insurance objectives.
¥ I understand that if I decide that this policy is not suitable for my needs, a full refund of the premiums less any expenses incurred will be made to
me upon receipt of my written notification of cancellation to Aviva at its Registered Office within 14 days from the date I receive my policy.
SAFGTL_AppForm-PDPA_A4_v2.0_Apr2018

Name & Signature of Member/Affiliate Member Signature of Dependant (Age 16 and above)
(Mandatory) (If applicable)

Date
 Singapore 068807
SGX Centre 2
4 Shenton Way #01-01
Aviva Ltd
ATTN: GROUP SALES

PERMIT No. 00645

BUSINESS REPLY SERVICE

Singapore only.
For posting in
paid by addressee.
Postage will be

Payment of Monthly Premium

1. For non-GIRO customers, Aviva will send you a premium notice once policy is accepted. For GIRO customers, deduction will take place once
the GIRO is approved.
2. For spouse and children, the premium will be deducted from the insured servicemanÕs GIRO account.
3. Submission of this application does not constitute an acceptance for insurance. An insurance certificate will be issued to you once your
application is underwritten and approved.
4. If you are currently insured and paying by GIRO, your monthly premium will be deducted from the same GIRO arrangement.
Application for Premium Payment by GIRO
¥ When completing the application form, please provide all relevant information in full to avoid unnecessary delay in the processing of
your application.
¥ Upon receipt of your application form, we will send it to your bank for verification and approval.
¥ It would take 1 to 3 weeks for your bank to approve your application.
¥ For DBS/POSB Account Holders, you can avoid the hassle of completing the INTERBANK GIRO FORM by applying for GIRO via iBanking.
Go to ibanking and select:

Pay (Bills and Cards) Add GIRO Arrangements Select Aviva IND HEALTH INS as Billing Organisation enter Ô0686xxxxxxxxÕ
as the reference number, ÔxxxxxxxxÕ denotes your NRIC number without prefix S or T.

¥ When your GIRO application has been approved, we will inform you of the start date of the premium deduction in writing. Before you receive
our notification, please continue to pay your premium in the usual manner.
¥ The first deduction will be made from your bank account on the 10th day of each month. If the first deduction fails, a second
deduction will be made on the 25th day of the same month. If the 10th or 25th falls on a Saturday, Sunday or Singapore Public Holiday,
deduction will be advanced to an earlier working day.
¥ Please note that for every unsuccessful debit due to insufficient fund, your bank may impose a service charge.
¥ For cancellation of GIRO arrangement, please inform Aviva in writing, three (3) weeks before the premium becomes due.
¥ For assistance, please contact our Customer Service Executives on hotline number (65) 6827 8000. Our Operating hours are from 8.45 a.m.
to 5.30 p.m., Mondays to Fridays, excluding Singapore Public Holidays.
Change of Interbank GIRO Account
1. You are advised not to terminate your existing bank GIRO account, until your new bank had validated and approved the new GIRO arrangement.
If you have to terminate your current bank GIRO account, you would have to submit a cheque for 4 months advance premium together with
this fresh GIRO application form.
2. Cheque must be crossed and made payable to ÔAviva LtdÕ. Please write your NRIC, full name, MINDEF & MHA Group Insurance and contact
number on the reverse side of your cheque. PLEASE DO NOT POST-DATE YOUR CHEQUE. No receipt will be issued for cheque payments.