I have read and agree to the following Authorization Statement By submitting this claim document, I understand, declare, and warrant that
- All information or data I provide, disclose, transmit, or attach to this Online Claim Submission is true, accurate, complete, and up-to-date as of the current circumstances, and I agree to guarantee and take responsibility for the accuracy of this information or data.
- All data I provide, disclose, transmit, or attach to this Online Claim Submission will form the basis and part of the Policy.
- If I am found to have provided data, statements, information, and answers that are intentionally or unintentionally untrue or incomplete, I am aware, understand, and agree that PT. AXA Insurance Indonesia has the right to cancel this Policy, without the obligation to pay any benefits or refund any premiums I have paid.
- I have read, understood, and agreed to the terms and conditions of the Policy. In this regard, I understand, declare, and warrant that my heirs, family members, or anyone acting on my behalf forever release and discharge PT. AXA Insurance Indonesia, its directors, commissioners, employees, and/or affiliates from any form of legal action or claim I may have or may have in the future, directly and/or indirectly related to the use of my data, and if in the future there is data and written correspondence related to this Online Claim Submission and/or Policy that is not correct, I am willing to be held accountable according to applicable laws and regulations.
- PT. AXA Insurance Indonesia is allowed to store, use, and disclose my data to any third parties (as necessary) in connection with the claims process.