Hong Kong Jockey Club Group Critical Illness Plan Enrollment Declaration

1. I/We hereby apply for the Group Critical Illness Insurance (“Plan”). I/We declare that to the best of my/our knowledge and belief the information on this enrollment form is true and complete in every respect and all information disclosed have been verified by me/us as true and correct. Where applicable, I/we declare that I/we have full and complete authority from the insured person(s) to submit on their behalf this application and disclose any personal information being requested to assess this application. I/We understand and agree that this enrollment form and declaration will form the basis of the contract between me/us and Zurich Insurance Company Ltd (the “Company”).
2. I/We authorize the Company to obtain the necessary medical information from the insured person’s medical practitioner(s) and I/we agree to supply additional information relevant to the policy of this Plan at my/our own expense.
3. I/We understand that I/we shall refer to the policy of this Plan for details of the insurance coverage, exclusion clauses and terms and conditions.
4. I/We understand I/we must complete and provide all information requested in this enrollment form, failing which the Company cannot process my application for this Plan.
5. I/We declare that the insured person(s) is/are in good health and free from physical and mental impairment or deformity.

This insurance application will not be in force until the application(s) has been accepted by the Company and the premium has been paid.