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 confirm that I understand and agree to the 'Personal data collection statement'.
6. I agree that if I or any ^#Relevant Person is found to be a ⁺Prohibited Person:
   • you are entitled not to accept this application; and
   • if any policy is issued, you are entitled to end this policy, not pay any benefit or not allow any transaction, such as surrender and assignment, to be carried out under this policy. You will not refund any unutilised premium when this policy is ended.
   Your decision in every respect of the above will be final. I will inform you immediately if there is any change in my or any Relevant Person’s identity, status or identity documents.

^#Relevant Person includes insured, trustee, settlor, beneficiary, assignee, nominee, payee, mortgagee, financier of this application/policy, and in relation to an entity, its director, partner, manager, person having executive authority, authorised signatory, shareholder or beneficial owner.

⁺Prohibited Person means a person or entity who is, or who is ^{^}Related to a person or entity:

• subject to laws, regulations or sanctions administered by any inter-government, government, regulatory or law enforcement authorities of any country, which will prohibit or restrict you from providing insurance or carrying out any transaction under this policy, or

• who is involved in any terrorist or illegal activities or placed on sanctions listing or issued with freezing order.

^{^}Related includes relationships such as parent, step-parent, child, step-child, adopted child, spouse, sibling, step-sibling, adopted sibling, parent-in-law, child-in-law, sibling-in-law, cousin, uncle, aunt, grandparents, niece, nephew, grandchild, employee, employer, associate, parent company, subsidiary and shareholder.

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.