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1.

本人於本索償所提供的一切資料為本人所知的全部及為真確無誤。

2.

本人確認為 (i)團體保險保單之受保成員 及/或 (ii)個人保險保單之持有人。所提供作保險索償的身份證明資料，乃本人以受保成員及/或個人保險保單之持有人之身份所持有。本人明白「提交電子索償申請」只是整個索償程序的一部份，而在祥昇保險代理完成整個索償程序之前，本人／家屬(如適用)將不會獲得任何索償金額。本人明白保險中介人或會協助處理有關電子索償申請的跟進事宜。

3.

本人授權任何醫生、醫學界執業人士、醫院、診所或其他與醫療有關的機構、保險公司或其他組織、機關或人士，將其所有關於本人(i)團體保險保單之受保成員 及/或 (ii)個人保險保單之受保人（「受保人」）或受保成員的家屬（「受保家屬」）的記錄或健康狀況資料，提供予祥昇保險代理。此授權書是不可撤銷的，即使本人去世，此授權仍然生效。此授權書的影印本將與正本同樣有效。從本人／吾等／本人的家屬、保單持有人及擬受保人所收集的資料（包括但不限於個人資料、健康資料及索償記錄），可供祥昇保險代理用於經營保險/金融業務之用，並可供：i) 祥昇保險代理、其關聯公司、僱員、第三方供應商/服務供應商、再保險公司及／或分銷商使用於以下目的：(a) 處理本人申請，包括但不限於釐定資格及批核申請；(b) 核保；(c) 處理索償，包括但不限於管理、評估、裁決、調查、徵求外部專業意見、支付款項、差額管理、代位申索、分析及匯報事宜；(d) 付款請求及／或信貸服務；(e) 管理保單或有關保單的任何變更、取消或續期事宜；(f) 偵查及防範欺詐（無論是否與本申請書所簽發的保單有關）；(g) 提供客戶服務，包括但不限於跟進相關查詢，以及／或與閣下及／或閣下代表之間的通訊事宜；(h) 祥昇保險代理、祥昇保險代理的關聯公司或保險／金融行業所開展的統計或精算研究工作；(i) 基於自動化／人工智能的決策或分析；(j) 遵守適用法律、法規及其他相關目的。ii) 轉移至(a)任何相關公司或其他從事保險或再保險相關業務的公司、中介人、提供保險相關服務的索償、調查或其他機構，或任何現存或不時成立的監管/法定機構、協會或保險公司聯會；(b)以實現上述任何一項目的及/或以核對程序或其他方式進行數據核實、以及／或進行保單再保險事宜的任何個人／組織；(c) 醫護專業人員、醫院、會計師、法律顧問、僱主； (d) 為保險業整合索償及核保資料的機構、防範欺詐機構、其他保險公司（無論是直接轉移至或透過防範欺詐機構或本段所述之其他人士作出轉移）、執法機構、可供保險業界根據現有資料進行資料分析和核實的數據庫或登記冊（及其營運者）。

4.

如本人以受保成員身份為受保家屬提交索償申請，或本人以個人保單之持有人提交索償申請，本人確認已向所有受保家屬/受保人取得授權，可(a)向祥昇保險代理提供其資料；及(b)將所有其提供的資料由祥昇保險代理傳回給本人。本人亦明白本索償內提供的資料是讓祥昇保險代理作處理此索償之用。

5.

本人有權以書面通知祥昇保險代理，要求索閱及更改本人之個人資料（如需要）。

6.

祥昇保險代理可按於《有關〈個人資料（私隱）條例〉的客戶通知》（「通知」）所述，處理有關資料。假如本人或受保人或受保家屬未有細閱該通知/聲明（如適用），本人明白本人，或本人需確保受保人/受保家屬可從祥昇保險代理取得該通知/聲明（如適用）。

7.

本人更特此同意及授權祥昇保險代理於賠償金額內扣除本人或受保家屬尚未清還予祥昇保險代理之任何欠款，不論任何原因。本人亦明白並同意祥昇保險代理有權要求因處理索償時所需的資料不確/遺漏而退回任何已賠償之金額。

8.

我確認本索償沒有提交給其他保險公司。或如索償已經提交給其他保險公司，我已隨附該保險公司的賠償通知書。本人明白為審查所需，祥昇保險代理可能會在索償完成日期起計九十日內或理賠批核前之指定期間內要求本人將本人/受保家屬的電子索償申請之有關醫療收據/收條正本及證明文件（「文件正本」）遞交至祥昇保險代理作審查用途。倘若本人收到祥昇保險代理此等要求之通知，本人承諾及同意立即向祥昇保險代理提交文件正本。倘若本人未能提供文件正本，或所提交之文件正本乃為虛假、偽造、或含欺騙成份，祥昇保險代理將保留權利包括但不限於拒絕接受本人或受保家屬以後的電子索償申請及/或暫停處理是次電子索償申請。

9.

本人同意祥昇保險代理將有關由本人提供的所有資料傳回給保單持有人（即僱主）。本人亦明白本表格內提供的資料是讓祥昇保險代理作處理本人索償之用。

10.

如有關保單繕發於香港，則以上條款及細則乃根據香港法律而詮釋並受制于香港之司法管轄權。本人已經細讀及接受此「聲明及授權書」之所有資料及內容。

11.

本聲明及授權書之英文、繁體中文和簡體中文版本如有任何歧異，概以英文版本為準。

1.

All information provided by me for this claim is complete and true to the best of my knowledge and belief.

2.

I confirm I am (i) a policy insured member ("Insured Member") and/or (ii) a Individual Insurance policy owner. The identity information I provide herein is either owned by me as the Insured Member or Individual Insurance policy owner as part of this claim submission process.I understand that "Submit eClaim application" is part of the claim process and I or the dependent (where applicable) will not be entitled to any payment of claim until the entire claim process is considered by Insurance Companies to be completedI understand that any subsequent claims follow up may involve my insurance advisor in administering the eClaim submission.

3.

I authorize any physician, medical practitioner, hospital, clinic or other medically related facility, insurance company or other organization, institution or person that has any records or knowledge of me, the insured under (i) Group Life and Health Policy and/or (ii) the Individual Insurance policy ("Insured") or the dependent of an Insured Member ("Dependent") to provide to insurance companies any such information. Such authorization shall survive me and shall be irrevocable. A photocopy of this authorization shall be as valid as the original.Information (including but not limited to personal data and health information and claims history) collected from me/us/my dependent, the policyowner/policyholder and the proposed insured, can enable Peaceful Insurance Agency Limited to carry on its insurance/financial business and may be:i) used by Peaceful Insurance Agency Limited, its associated companies, employees, third-party vendors/service providers, reinsurers and/or distributors for the purpose of (a) processing my application, including, but not limited to, determining eligibility and approval; (b) underwriting; (c) handling claim(s) including, but not limited to, administering, assessing, adjudicating, investigating, seeking external professional advice, disbursing payment, shortfall management, subrogation, analysis and reporting; (d) requests for payment and/or credit services; (e) administering the policy or any alterations, cancellation or renewal of it; (f) detecting and preventing fraud (whether or not relating to the policy issued in respect of this application); (g) providing customer service, including but not limited to, any follow up on related enquiry and/or communication with you and/or your representative(s); (h) statistical or actuarial research of Peaceful Insurance Agency Limited, Peaceful's associated companies or the insurance/financial industry; (i) automated/ artificial intelligence decision making or profiling; (j) complying with applicable laws, regulations and other related purposes;ii) transferred to (a) any related company or other company carrying on insurance or reinsurance related business or an intermediary or a claims or investigation or other service provider providing services relevant to insurance business or any regulatory/statutory bodies, association or federation of insurance companies that exists or is formed from time to time; (b) any person/organization to fulfill any of the above purposes and/or for the purpose of data verification by way of matching procedures or otherwise; and/or reinsurance of the policy; (c) health care professionals, hospitals, accountants, legal advisors, employers; (d) organisations that consolidate claims and underwriting information for the insurance industry, fraud prevention organisations, other insurance companies (whether directly or through fraud prevention organisation or other persons named in this paragraph), law enforcement agencies and databases or registers (and their operators) used by the insurance industry to analyse and check information provided against existing information.

4.

If a claim is submitted by me as the Insured Member for the Dependent / If a claim is submitted by me as the Individual Insurance policy owner, then I confirm that I have obtained the necessary authorization from the Dependent / the Insured to (a) supply his/her information to Peaceful Insurance Agency; and (b) transfer all supplied information from Peaceful Insurance Agency to me. I also understand that the information requested in this claim is required in order for Peaceful Insurance Agency to process this claim.

5.

By writing to Peaceful Insurance Agency, I can request access to and correction of my personal data (if appropriate).

6.

All information may be treated by Peaceful Insurance Agency in the same manner as mentioned in the "Notice to Customers relating to the Personal Data (Privacy) Ordinance" ("Notice") (for Hong Kong policy) / Peaceful Insurance Agency Personal Information Collection Statement ("Statement"). In case I or the Insured or the Dependent have/has not read the Notice / Statement (where applicable) before, I understand that I, or I shall ensure that the Insured / the Dependent (where applicable) will understand that he/she can obtain such Notice / Statement (where applicable) from Peaceful Insurance Agency. 

7.

I also hereby agree with and authorize Peaceful Insurance Agency to deduct from the reimbursement of the claim payment, in the event that, I or the Dependent, have/has any shortfall, for whatever reason.Peaceful Insurance Agency also has the right to reverse / claim back any incorrect payments caused by incorrect/ omission of required information provided in processing the claim.

8.

I confirm that this claim has not been processed by other insurer(s). Or the relevant Payment Advice is attached herewith if it has been processed by other insurer(s).I understand that for the purpose of auditing any of my/ the Dependent, I may be requested by Peaceful Insurance Agency to submit any or all original bill(s)/receipt(s) and supporting document(s) of the corresponding medical treatment/service received ("the Original Documents") within a period of 90 days counted from the claim completion date or such period as may be advised before claims approval. If I receive such a request, I undertake and agree to immediately submit the Original Documents to Peaceful Insurance Agency. In the event that I fail to accede to such request or the submitted Original Documents are found to be untrue, fake or misleading, Peaceful Insurance Agency  reserves all the rights including but without limitation not to accept any further eClaim application from me or the Dependent and/or not to proceed current eClaim application from me or the Dependent.

9.

I agree Peaceful Insurance Agency to transfer back all supplied information from me to the policyholder (i.e. the Employer).I also understand that the information requested in this form is required in order for Peaceful Insurance Agency to process this claims.

10.

These terms and conditions shall be governed by and construed in accordance with the laws of Hong Kong and subject to the exclusive jurisdiction of Hong Kong courts.I have read and accepted the information and content provided in this entire "Declaration and Authorization"

11.

In case of any inconsistency between the English version, Traditional Chinese version and Simplified Chinese version of these Terms and Conditions, the English version shall prevail.