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 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 untill 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 againts me.
6. I confirm that I understand and agree to the 'Personal data collection statement'.

You must give all the fact truthfully when you make this application. If you fail to reveal any information that may affect 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 include 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.