As part of the implementation of the United States Foreign Accounts Tax Compliance Act (FATCA), AXA Mansard is obliged to disclose certain customer information on US citizen and US owned entities to the Internal Revenue Service (IRS) if required. Kindly indicate your consent for AXA Mansard to render such information to the IRS by ticking this box

Please note that where applicable, where a customer does not provide the requisite documentation to AXA Mansard in line with the United States Foreign Accounts Tax Compliance Act (FATCA) requirements within 90 days from the date the request was made, 30% of such inflows/funds will be withheld for onward transmission to the US Government

I, the Life Assured, do hereby declare that all the foregoing answers are true, that I have not concealed nor withheld anything with which the Assurer should be acquainted with in order to assess my eligibility for assurance. I agree that these and all statements I have made or shall make to the Assurer or to its medical examiner(s) in connection with this or previous proposal(s) shall be the basis of this contract. I irrevocably authorize and request any Doctor or other person who may be in possession of, or hereafter acquire, any information concerning my health up to the present time and to disclose such information(s) to the Assured. I agree that this authority and request shall remain in force after my death as well as prior thereto.

Restrictions – War and Kindred Risks

It is agreed and expressly understood that should the death of the Life Assured occur directly or indirectly from and his / her engaging in or taking part in riot, strike, civil commotion, mutiny insurrection, war (whether war be declared or not), or any act incidental thereto, the total amount payable under this policy shall be limited to the total contributions made together with the total interest accrued thereon.

The Assurer shall not recognize any claim arising from any medical impairment or condition of a Life Assured which occurred or which was diagnosed prior to commencement of the term of assurance under this Policy, or within six (6) months of such commencement.

Kindly ensure all payments are made directly into AXA Mansard's designated corporate account(s). All cash payments MUST be made in person, as the company shall not be held liable for cash payments made to/through other third parties apart from NAICOM licensed Insurance brokers.