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I/We, the policyholder confirm that the information I/We have provided is my/our personal data. If personal data of third parties is provided (e.g. information of insured persons, dependents, payees and/or employees) to ERGO, I/We represent and warrant to ERGO that prior consents have been obtained from each of the third parties to provide such information. By providing this information I/We understand, acknowledge and consent that:

• ERGO Insurance Pte. Ltd. (ERGO) may/will collect, use, disclose and/or process my/our personal data for the purpose of enabling ERGO to provide me with services required of an insurance provider, such as evaluating, processing, administering, and/or managing my/our relationship and policies with ERGO and for the purposes stated in ERGO’s Personal Data Protection Policy;

• ERGO may/will also collect personal data about me/us from sources other than my/our self for one or more of the above Purposes, and thereafter using, disclosing and/or processing such personal data accordingly;

• ERGO may/will disclose my/our personal data to third parties, including but not limited to its affiliates, representatives, agents, service providers, and lawyers/law firms, whether located within or outside Singapore, for one or more of the mentioned purposes, as such third party if engaged by ERGO, would be processing my/our personal data for one or more of the above purposes;

• The personal data protection clauses herein are not exhaustive. I/We have read, understood and accept the terms of ERGO’s Personal Data Protection Policy found at http://www.ergo.com.sg/pdpa;



Authorized Agent of: