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I declare that the statements made in this proposal are true in every respect and that I have not withheld any information requested therein. I further declare and confirm that any information about the Beneficiary/Beneficiaries given in this proposal are also accurate and provided by themselves to me and that I have personally ensured that there is no information that has been withheld about them. I also declare that I have full authority to disclose the information in the proposal including the personal information of the Beneficiary/Beneficiaries. I understand and agree that the information, statements provided and this declaration and that if any untrue averment be contained regardless of such information is about me or Beneficiary/Beneficiaries the said contract shall be absolutely null and void. 

I undertake to facilitate obtaining of any information with respect to me and/or Beneficiary/Beneficiaries for the Company should the Company request for such additional information. I agree to inform the Company of any changes in occupation between the date of this proposal and date of acceptance. I fully understand that my failure to facilitate obtaining of information and informing of changes as aforementioned as required by the Company may render the Company not providing my requested insurance cover or refuse the issuance of any insurance cover to me.

I fully understand that the Company and its affiliates ("the Group") are subject to and required to, or has agreed to, comply with certain legal, regulatory and/or other requirements (the "Reporting Requirements"). As such, I provide my express consent that the Company shall have the right to provide such information to any governmental authorities, regulatory bodies and/or any other person(s) in respect of the Reporting Requirements. I understand that such disclosures may involve the cross border transfer of personal data outside the jurisdiction and that such disclosures may be with respect to i) the personal data of the Policy Owner, the Life Assured, other insureds and the Beneficiaries ("the Parties"), or any of them; ii) any information relating to this Policy; and iii) any information relating to any other policies held by the Parties or any of them. I understand that the Company will not be able to sell any insurance product to me and provide any service if I refuse to give the said express consent. I agree that should any of the Parties become a US citizen or resident while this Policy is in force, I shall promptly notify in writing to the Company, and in any event, no later than 30 days of me/them becoming a US citizen or resident. I provide this acceptance, consent and undertaking with respect to information of my spouse, children as well for and on behalf of them and as authorized by them.

By purchasing this Policy and signing below, “I hereby declare, agree and represent that I am not a “U.S. person(s)” for U.S. federal income tax purposes and that I am not acting for, or on behalf of a U.S. person.”

Below paragraph applies only to:

(i) United States (U.S.) persons for U.S. federal income tax purposes; or

(ii) If your tax status changes and you become a U.S. Person; or

(iii) You or your Beneficiaries in connection with this Policy have indicated through information provided to us that you or such beneficiary may be in fact a U.S. person for U.S. federal income tax purposes (including for example a US address, a US telephone number, TIN etc.). 

The term “U.S. Indicia” as used below refers to the any one of the three circumstances described in (i) to (iii) above.

In the event you have U.S. Indicia and fail after request to provide such information, consent, and/or assistance as the Company may from time to time require to allow it to comply with its contractual, legal and/or regulatory obligations under the United States Foreign Account Tax Compliance Act, including any required reporting to the Internal Revenue Service of information relating to you or Nominees/Beneficiaries in connection with this proposed insurance policy, the Company reserves the right and shall be entitled to cancel the insurance policy issued based on this Proposal Form.

I authorize and consent to AIA Insurance Lanka Limited (“Company”) to use my mobile and or other contact details for further communications with me and to obtain additional information regarding any matter pertaining to the assessment and processing of this proposal regardless of whether this proposal is accepted or not. I understand that such telephone conversations may be recorded, and any information given by me shall form part and parcel of this proposal and fulfil my duty of full disclosure of information. I agree to receive all the correspondence from the Company via electronic means such as SMS, emails or post.

By providing my personal information and personal information about my spouse, children, parent/s and/or of any third party/parties as life assured/beneficiaries/nominees/assignees to the Company, I accept that the Company may retain such information for as long as necessary for life insurance contract, to fulfil the purpose(s) for which it is collected in compliance with laws and regulations of the country and I hereby confirm that full consent of such parties have been duly obtained by me for the submission and processing of their personal information by the Company as mentioned herein and in accordance with the privacy statement  available on the Company's website and I have been given the full authority from such parties to deal with their respective information I herein provided and will be provided in the future.

I confirm that I am fully aware of the fact that all the personal information obtained hereunder is collected for the purposes of assessing, processing, evaluating and determining this proposal and if a life insurance policy is issued based on this proposal, then to provide the necessary services as per the relevant life insurance policy, such personal information will be transferred to AIA’s authorized investigators, medical panels or its relevant associates / nominees / subsidiaries (“third party administrators”). I authorize the Company to transfer all personal information collected hereunder to the third party administrators, stakeholders in the industry, medical professionals, institutions, or other entities involved in the provision of connected services including the underwriting of this proposal and servicing of the life insurance policy, if issued based on this proposal, and further give my consent to all third party administrators who / which are in receipt of this personal information that they may process my personal information and transfer all processed personal information to the Company for the evaluation and approval of this proposal and provide insurance services in terms of the life insurance policy, if a policy is issued. I understand that without my voluntary consent, personal information collected will not be transferred to the third-party administrators and I am aware that if I choose not to provide the personal information required and or do not consent for sharing of such personal information as herein explained, that will result in me not qualifying for receiving any of the services hereunder.

I am aware that the Company recognizes its responsibilities in relation to the collection, holding, processing or use of my personal data. I understand the privacy statement available on the Company's website provides with notice as to why personal data is collected, how it is intended to be used, to whom such personal data may be transferred to, use of another processer or third country involvement, how to access, review, and amend such personal data, the Company policies on the use of cookies. In addition, I consent to Company sharing such personal information with its third-party business partners and to receive any promotional and marketing communications relating to their products and services.

I consent to receive notifications, updates, and other communications from AIA Insurance Lanka Limited via electronic means regarding my policy, claims, and related services. I understand that I can opt out at any time by unsubscribing to emails, replying “STOP” to SMS, or by contacting AIA Insurance Lanka Limited and I am also aware that such unsubscribing may prevent myself from receiving important information that the Company may address to me and I declare that I will not hold the Company responsible in any manner whatsoever in the event any loss is incurred by me or any other party whose information I have provided to the Company, by the reason of not receiving such important information by me.

Additionally, I consent to AIA Insurance Lanka Limited verifying my National Identity Card (NIC) details with the Department of Registration of Persons (DRP), as deemed necessary for further screening and administration and management of my policy and claims, if a policy is issued.

I understand and agree that all personal and sensitive information will be handled by the Company in accordance with applicable data protection laws, including the Personal Data Protection Act No. 9 of 2022, and I have pursed the privacy statement available on the  Company website and hereby confirm that I have read, understood and fully consent and agree to be abide by the terms and conditions of the said privacy statement.

I, the undersigned, hereby acknowledge and declare that the Company or the salesperson has dully explained to me the benefits, additional benefits, exclusions, terms and conditions, claim and complaints handling procedure of this Policy. I further confirm that I am satisfied with the explanations provided and fully understand all aspects of the product and agree to abide by the terms and conditions outlined. 

මෙම රක්ෂණ ඔප්පුවේ සඳහන් ප්‍රතිලාභ, අමතර ප්‍රතිලාභ, බැහැර කිරීම්, නියමයන් සහ කොන්දේසි  හිමිකම්පෑම් සහ ආරවුල් විසඳීමේ ක්‍රියා පටිපාටිය පිළිබඳව සමාගම හෝ අලෙවිකරුවන් විසින් මට පැහැදිලි කර ඇති බව පහත අත්සන් කර ඇති මම මෙයින්  පිළිගෙන ප්‍රකාශ කරමි. සපයා දුන් පැහැදිලි කිරීම් පිළිබඳව මා සෑහීමකට පත්වන බවත්, මෙම රක්ෂණවරයේ සියලුම අංග සම්පූර්ණයෙන්ම අවබෝධ කරගත් බවත්, දක්වා ඇති නියමයන් හා කොන්දේසි වලට අනුකූල වීමට එකඟ වන බවත් මම තවදුරටත් පිළිගනිමි.

இந்தக் கொள்கையின் பயன்கள், விலக்குகள், விதிமுறைகள் மற்றும் நிபந்தனைகள், உரிமைகோரல் மற்றும் புகார்களைக் கையாளும் நடைமுறை ஆகியவற்றை நிறுவனம் மற்றும் விற்பனையாளர் எனக்கு விளக்கமளித்துள்ளார் என்பதை கீழே கையொப்பமிடப்பட்ட நான் இதன் மூலம் ஒப்புக்கொண்டு அறிவிக்கிறேன். வழங்கப்பட்ட விளக்கங்களில் நான் திருப்தி அடைகிறேன் மற்றும் தயாரிப்பின் அனைத்து அம்சங்களையும் முழுமையாகப் புரிந்துகொள்கிறேன் மற்றும் கோடிட்டுக் காட்டப்பட்டுள்ள விதிமுறைகள் மற்றும் நிபந்தனைகளுக்கு இணங்க ஒப்புக்கொள்கிறேன் என்பதை மேலும் உறுதிப்படுத்துகிறேன்.