Declaration and authorization

1. I have not withheld any material information relating to this application. I accept full responsibility for it.
2. I agree that this application and other written statements, information or declaration I have made or made on my behalf, will form the basis of the contract of insurance between me and Income. 
3. I acknowledge that you will not be legally responsible for any claims until you have accepted this application and you have received the premium in full.
4. I am aware that I can get advice from a qualified adviser before I sign this application. If I choose not to, I take full responsibility for making sure that this product is appropriate for my financial needs and insurance aims. 
5. I declare that I am not an undischarged bankrupt and no bankruptcy application (including any statutory order) or order has been made against me.
6. I confirm that I understand and agree to the ‘Personal data use statement’.
7. For the purpose of processing and/or administrating this application and any claim in connection with my/our policy(ies) with Income, I/we authorise, consent to, and agree to any medical source, insurance office, reinsurance, or organisation to release to you and you to release to any medical source, insurance office, reinsurance, or organisation any relevant information to do with me or the insured whether you accept my application or not.
8. I agree that if I or any *Relevant Person is found to be a +Prohibited Person, you are entitled not to accept this application. Further, if any policy is issued, you will end this policy, not pay any benefit or allow any transaction to be carried out under this policy such as assignment, if I or any Relevant Person is a Prohibited Person, and your decision will be final. You will not refund any unutilised premium when this policy is ended. I will inform Income immediately if there is any change in my or any Relevant Person’s identity, status or identity documents.
   
   *Relevant Person includes insured, trustee, assignee, beneficiary, beneficial owner or nominee and mortgagee or financier.
   +Prohibited Person means a person or entity who is subject to laws, regulations or sanctions administered by any governmental or regulatory authorities or law enforcement in any country, which will prohibit you from providing insurance cover or paying any benefit.

You must give all the facts truthfully when you make this application. If you fail to reveal any material information in this application, you may not receive any benefits under your policy. If you are in doubt as to whether a fact is material, you should reveal it anyway. This includes any fact which you may have given to the adviser but is not written in this application. Please check to make sure you are fully satisfied with the information in this application.

Counter-indemnity

In return for us providing you with, whichever is applicable,;

1. a Letter of Guarantee for S$5,000, in favour of the Controller of Immigration, Singapore as security for keeping to all the conditions under the Security Bond; or
2. a Performance Bond for S$2,000 or S$7,000, in favour of the Philippine Overseas Labor Office, Philippines Embassy as security for keeping to all the conditions under the Philippines Embassy’s Standard Employment Contract for Filipino Household workers in Singapore.

You agree and undertake as follows:-

1. You will, at all times, compensate us against all claims, payments, demands, action suits, proceedings, losses, liabilities costs and expenses which we may incur under the above Letter of Guarantee or Performance Bond (each also referred to as the “Bond”). 
2. You will repay us within 14 days of any payment we make under the Bond. If you do not do so, you will have to pay additional interests at a rate of 8% a year from the date we make the payment under the Bond until the date we receive full payment from you.
3. You will also pay us all costs, charges and expenses including legal costs we may incur in enforcing or trying to get payment of all or any part of the money agreed to be paid.
4. We may settle out of court, all claims, payments, demands, action suits, proceedings, losses and liabilities which may be taken or made against you under the Bond.
5. All receipts, vouchers, statement of account or other evidence of payments we have made or of all liabilities or obligations we have because of the letter of guarantee or insurance bond will be evidence against you and your estate of the amount you owe us.
6. This counter indemnity will continue indefinitely and your legal responsibility will not be affected even if we decide to give you extra time to pay, or accept other offers from you, or make other arrangements with you, or extend the validity of the Bond.
7. This counter indemnity will stay in force (even when the Bond ends) until we have no further liability under the Bond.
8. Any demand we make can be given in writing to you by our servant, agent, employee or lawyer either serving it personally on you or sending it by post to you at your last known address.
9. Anyone who is not involved in this counter indemnity will have no rights under the Contracts (Rights of Third Parties) Act (cap. 53B) to enforce any of the terms in it.
10. This counter indemnity is governed by the laws of the Republic of Singapore and you and we agree that any disputes will be heard by the Singapore courts.
11. Only where applicable, if you pay extra premium for waiver of this counter indemnity for the Letter of Guarantee in favour of the Controller of Immigration, Singapore, you will only be liable to pay us the first $250 in excess in the event the Ministry of Manpower calls on your Security Bond; provided that the conditions of the Security Bond was not broken as a result of your negligence, deliberate, wilful or criminal act, and subject to the relevant exclusions as set out in the policy issued to you.

Declaration and authorisation

1. I have not withheld any material information relating to this application. I accept full responsibility for it. 
2. I agree that this application and other written statements, information or declaration I have made or made on my behalf, will form the basis of the contract of insurance between me and Income.
3. I acknowledge that you will not be legally responsible for any claims until you have accepted this application and you have received the premium in full.
4. I am aware that I can get advice from a qualified adviser before I sign this application. If I choose not to, I take full responsibility for making sure that this product is appropriate for my financial needs and insurance aims. 
5. I declare that I am not an undischarged bankrupt and no bankruptcy application (including any statutory order) or order has been made against me.
6. I confirm that I understand and agree to the ‘Personal data use statement’ and the ‘Counter Indemnity’.
7. For the purpose of processing and/or administrating this application and any claim in connection with my/our policy(ies) with Income, I/we authorise, consent to, and agree to any medical source, insurance office, reinsurance, or organisation to release to you and you to release to any medical source, insurance office, reinsurance, or organisation any relevant information to do with me or the insured whether you accept my application or not.
8. I agree that any premium payable for issuance of the Performance Bond is non-refundable in any circumstance.
9. I agree that if I or any *Relevant Person is found to be a +Prohibited Person, you are entitled not to accept this application. Further, if any policy is issued, you will end this policy, not pay any benefit or allow any transaction to be carried out under this policy such as assignment, if I or any Relevant Person is a Prohibited Person, and your decision will be final. You will not refund any unutilised premium when this policy is ended. I will inform Income immediately if there is any change in my or any Relevant Person’s identity, status or identity documents.
   
   *Relevant Person includes insured, trustee, assignee, beneficiary, beneficial owner or nominee and mortgagee or financier.
   +Prohibited Person means a person or entity who is subject to laws, regulations or sanctions administered by any governmental or regulatory authorities or law enforcement in any country, which will prohibit you from providing insurance cover or paying any benefit.

You must give all the facts truthfully when you make this application. If you fail to reveal any material information in this application, you may not receive any benefits under your policy. If you are in doubt as to whether a fact is material, you should reveal it anyway. This includes any fact which you may have given to the adviser but is not written in this application. Please check to make sure you are fully satisfied with the information in this application.

Counter-indemnity

In return for us providing you with, whichever is applicable,:

1. a Letter of Guarantee for S$5,000, in favour of the Controller of Immigration, Singapore as security for keeping to all the conditions under the Security Bond; or
2. a Performance Bond for S$2,000 or S$7,000, in favour of the Philippine Overseas Labor Office, Philippines Embassy as security for keeping to all the conditions under the Philippines Embassy’s Standard Employment Contract for Filipino Household workers in Singapore.

You agree and undertake as follows:-

1. You will, at all times, compensate us against all claims, payments, demands, action suits, proceedings, losses, liabilities costs and expenses which we may incur under the above Letter of Guarantee or Performance Bond (each also referred to as the “Bond”). 
   If you pay the extra premium for the waiver of this counter indemnity for the Security Bond, you will only be liable to us as described above if you break any of the conditions under the Security Bond deliberately or as a result of your negligence. If any condition under the Security Bond is broken and this was not caused by your deliberate, wilful or criminal act, or negligence, you will only be liable to pay us the first S$250 excess.
2. You will repay us within 14 days of any payment we make under the Bond. If you do not do so, you will have to pay additional interests at a rate of 8% a year from the date we make the payment under the Bond until the date we receive full payment from you.
3. You will also pay us all costs, charges and expenses including legal costs we may incur in enforcing or trying to get payment of all or any part of the money agreed to be paid.
4. We may settle out of court, all claims, payments, demands, action suits, proceedings, losses and liabilities which may be taken or made against you under the Bond.
5. All receipts, vouchers, statement of account or other evidence of payments we have made or of all liabilities or obligations we have because of the letter of guarantee or insurance bond will be evidence against you and your estate of the amount you owe us.
6. This counter indemnity will continue indefinitely and your legal responsibility will not be affected even if we decide to give you extra time to pay, or accept other offers from you, or make other arrangements with you, or extend the validity of the Bond.
7. This counter indemnity will stay in force (even when the Bond ends) until we have no further liability under the Bond.
8. Any demand we make can be given in writing to you by our servant, agent, employee or lawyer either serving it personally on you or sending it by post to you at your last known address.
9. Anyone who is not involved in this counter indemnity will have no rights under the Contracts (Rights of Third Parties) Act (cap. 53B) to enforce any of the terms in it.
10. This counter indemnity is governed by the laws of the Republic of Singapore and you and we agree that any disputes will be heard by the Singapore courts.
11. Only where applicable, if you pay extra premium for waiver of this counter indemnity for the Letter of Guarantee in favour of the Controller of Immigration, Singapore, you will only be liable to pay us the first $250 in excess in the event the Ministry of Manpower calls on your Security Bond; provided that the conditions of the Security Bond was not broken as a result of your negligence, deliberate, wilful or criminal act, and subject to the relevant exclusions as set out in the policy issued to you.

Declaration and authorisation

1. I have not withheld any material information relating to this application. I accept full responsibility for it. 
2. I agree that this application and other written statements, information or declaration I have made or made on my behalf, will form the basis of the contract of insurance between me and Income.
3. I acknowledge that you will not be legally responsible for any claims until you have accepted this application and you have received the premium in full.
4. I am aware that I can get advice from a qualified adviser before I sign this application. If I choose not to, I take full responsibility for making sure that this product is appropriate for my financial needs and insurance aims.
5. I declare that I am not an undischarged bankrupt and no bankruptcy application (including any statutory order) or order has been made against me.
6. I confirm that I understand and agree to the ‘Personal data use statement’ and the ‘Counter Indemnity’.
7. For the purpose of processing and/or administrating this application and any claim in connection with my/our policy(ies) with Income, I/we authorise, consent to, and agree to any medical source, insurance office, reinsurance, or organisation to release to you and you to release to any medical source, insurance office, reinsurance, or organisation any relevant information to do with me or the insured whether you accept my application or not.
8. I agree that any premium payable for issuance of the Performance Bond is non-refundable in any circumstance.
9. I agree that if I or any *Relevant Person is found to be a +Prohibited Person, you are entitled not to accept this application. Further, if any policy is issued, you will end this policy, not pay any benefit or allow any transaction to be carried out under this policy such as assignment, if I or any Relevant Person is a Prohibited Person, and your decision will be final. You will not refund any unutilised premium when this policy is ended. I will inform Income immediately if there is any change in my or any Relevant Person’s identity, status or identity documents.
   
   *Relevant Person includes insured, trustee, assignee, beneficiary, beneficial owner or nominee and mortgagee or financier.
   +Prohibited Person means a person or entity who is subject to laws, regulations or sanctions administered by any governmental or regulatory authorities or law enforcement in any country, which will prohibit you from providing insurance cover or paying any benefit.

You must give all the facts truthfully when you make this application. If you fail to reveal any material information in this application, you may not receive any benefits under your policy. If you are in doubt as to whether a fact is material, you should reveal it anyway. This includes any fact which you may have given to the adviser but is not written in this application. Please check to make sure you are fully satisfied with the information in this application.

Counter-indemnity

In return for us providing you with, whichever is applicable,:

1. a Letter of Guarantee for S$5,000, in favour of the Controller of Immigration, Singapore as security for keeping to all the conditions under the Security Bond; or
2. a Performance Bond for S$2,000 or S$7,000, in favour of the Philippine Overseas Labor Office, Philippines Embassy as security for keeping to all the conditions under the Philippines Embassy’s Standard Employment Contract for Filipino Household workers in Singapore.

You agree and undertake as follows:-

1. You will, at all times, compensate us against all claims, payments, demands, action suits, proceedings, losses, liabilities costs and expenses which we may incur under the above Letter of Guarantee or Performance Bond (each also referred to as the “Bond”). 
2. You will repay us within 14 days of any payment we make under the Bond. If you do not do so, you will have to pay additional interests at a rate of 8% a year from the date we make the payment under the Bond until the date we receive full payment from you.
3. You will also pay us all costs, charges and expenses including legal costs we may incur in enforcing or trying to get payment of all or any part of the money agreed to be paid.
4. We may settle out of court, all claims, payments, demands, action suits, proceedings, losses and liabilities which may be taken or made against you under the Bond.
5. All receipts, vouchers, statement of account or other evidence of payments we have made or of all liabilities or obligations we have because of the letter of guarantee or insurance bond will be evidence against you and your estate of the amount you owe us.
6. This counter indemnity will continue indefinitely and your legal responsibility will not be affected even if we decide to give you extra time to pay, or accept other offers from you, or make other arrangements with you, or extend the validity of the Bond.
7. This counter indemnity will stay in force (even when the Bond ends) until we have no further liability under the Bond.
8. Any demand we make can be given in writing to you by our servant, agent, employee or lawyer either serving it personally on you or sending it by post to you at your last known address.
9. Anyone who is not involved in this counter indemnity will have no rights under the Contracts (Rights of Third Parties) Act (cap. 53B) to enforce any of the terms in it.
10. This counter indemnity is governed by the laws of the Republic of Singapore and you and we agree that any disputes will be heard by the Singapore courts.

Declaration and authorisation

1. I have not withheld any material information relating to this application. I accept full responsibility for it. 
2. I agree that this application and other written statements, information or declaration I have made or made on my behalf, will form the basis of the contract of insurance between me and Income. 
3. I acknowledge that you will not be legally responsible for any claims until you have accepted this application and you have received the premium in full. 
4. I am aware that I can get advice from a qualified adviser before I sign this application. If I choose not to, I take full responsibility for making sure that this product is appropriate for my financial needs and insurance aims. 
5. I declare that I am not an undischarged bankrupt and no bankruptcy application (including any statutory order) or order has been made against me.
6. I confirm that I understand and agree to the ‘Personal data use statement’ and the ‘Counter Indemnity’.
7. For the purpose of processing and/or administrating this application and any claim in connection with my/our policy(ies) with Income, I/we authorise, consent to, and agree to any medical source, insurance office, reinsurance, or organisation to release to you and you to release to any medical source, insurance office, reinsurance, or organisation any relevant information to do with me or the insured whether you accept my application or not.
8. I agree that any premium payable for issuance of the Performance Bond is non-refundable in any circumstance.
9. I agree that if I or any *Relevant Person is found to be a +Prohibited Person, you are entitled not to accept this application. Further, if any policy is issued, you will end this policy, not pay any benefit or allow any transaction to be carried out under this policy such as assignment, if I or any Relevant Person is a Prohibited Person, and your decision will be final. You will not refund any unutilised premium when this policy is ended. I will inform Income immediately if there is any change in my or any Relevant Person’s identity, status or identity documents.
   
   *Relevant Person includes insured, trustee, assignee, beneficiary, beneficial owner or nominee and mortgagee or financier.
   +Prohibited Person means a person or entity who is subject to laws, regulations or sanctions administered by any governmental or regulatory authorities or law enforcement in any country, which will prohibit you from providing insurance cover or paying any benefit.

You must give all the facts truthfully when you make this application. If you fail to reveal any material information in this application, you may not receive any benefits under your policy. If you are in doubt as to whether a fact is material, you should reveal it anyway. This includes any fact which you may have given to the adviser but is not written in this application. Please check to make sure you are fully satisfied with the information in this application.