Clinic Protect FORM

- I have read and understood the importance notices contained in this application.
- I agree that this proposal together with any other information will form the basis of any contract of insurance.
- I acknowledge that if this application is accepted, the contract of insurance will be subject to terms and conditions as set out in the policy wording as issued or as otherwise specifically varied in writing by Chubb or STMB
- I declare after inquiry that the statement, particulars and information contained in this application and in any document accompanying this application are true and correct in every detail and that no other material facts have been misstated, suppress or omitted .
- I undertake to inform Chubb or STMB of any material alteration to those facts before completion of the contract of insurance.
- I understand the Chubb or STMB needs to deal with our personal data to administer our Policy and offer us insurance products and services . To achieve these purpose ,I allow Chubb or STMB to collect, use and disclose our personal data to selected third parties in or outside Malaysia, in accordance with Personal Data Protection Notice