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Declaration and Authorization

I hereby apply for coverage on behalf of all the family members named in this application form. I hereby declare that the above statements are full, complete and true to the best of my knowledge, and that I have not declared or omitted to declare any particular that may mislead the Insurer. I and applicants named in this application, request to obtain the insuring agreement according to the terms and conditions of this policy. The Applicants declare and warrant that the above answers are true and complete. This application shall be the basis of the contract between the Applicants and the Company. If any of my statement is untrue or false, this policy becomes voidable. The company is entitled to void the policy according the Civil Commercial Code Section 865. I and applicants named in this application, authorize any doctor who has ever provided treatment or given advice to any persons named in this application to disclose information regarding the treatment that are related to any claim under this Policy. I have obtained the consent of all dependents named in this application to be enrolled to disclose their healthcare information in accordance with this authorization. If I have agreed to make payment via credit card, I authorize The Navakij Insurance Public Company Limited to debit my account with the appropriate premiums agreement dates or on their due dates. I also authorize subsequent renewal premiums to be invoiced by The Navakij Insurance Public Company Limited until I provide a written notice for the termination of this Agreement. I understand that the medical information of any persons named in this application form will be exchanged between the insurer and the medical professionals within its network. I authorize The Navakij Insurance Public Company Limited to send documents concerning this Policy to the home and/or billing address and email address I have provided or, upon my notification, to my intermediary’s address. I authorize the company to collect, utilize and disclose my health related facts and personal information to the Office of Insurance Commission for the purpose of insurance industry regulation. I understand that even if I have paid for my membership, I will be reimbursed the remaining premium after deducting actual medical check-up fee and company expenses per policy 500 Baht (if any) if I cancel within 15 days after I received the insurance policy, given that I have submitted no claims. Passed the 15 days deadline, The Navakij Insurance Public Company Limited reserves the right to withhold the amount relating to the period of actual coverage. The Company reserves the right to check medical history and diagnosis of the Covered Person, and has the right to conduct an autopsy, within the limits of the law, in case of death, and the expense incurred will be paid by the Company. If the Covered Person does not allow the company to investigate his claim or does not give permission to access his/her medical record or diagnosis, the company reserves the right not to pay such claims. Consent for the Company to collect, use or disclose health information I hereby give my consent to any doctor, medical facility, insurance company, organization, institution or person with medical records regarding my illness or injury, including facts about my medical history, to disclose all facts to The Navakij Insurance Public Company Limited or authorized person. I give my consent to the Company or authorized person to collect, use and disclose information about my health to the insurance company, reinsurance company, legal authority, and/or authorized person; for the purpose of insurance application, claims payment according to the policy or medical benefits.