Declaration and consent
This claim form collects claim related information about you, the Policy Owner, and any Life Assured for whom you are claiming under your Policy for the purpose of assessing the health insurance claim(s) under your policy.
The intended recipient of this claim related information is Sovereign Assurance Company Limited ('Sovereign') and/or any of its related companies, their officers, their advisers, their agents and reinsurers. This claim related information collected will be held at Sovereign's head office, 74 Taharoto Road, Takapuna and by Sovereign's data storage providers, including cloud-based data storage providers (whether in New Zealand or elsewhere). Both Sovereign and its cloud based data storage provider will take reasonable steps to keep such information secure.
Sovereign may be required to disclose this claim related information if disclosure is required by law, including laws of other jurisdictions, for example to government and regulatory authorities. Failure to provide the requested claim related information or provision of incorrect claim related information may result in this claim being declined or unable to be assessed. You and any Life Assured have the right to request access to, and correction of, your respective claim related information at any time.
I, the Policy Owner, hereby claim the benefit amounts payable on the basis of the statements and information provided by the Life Assured in this claim form which I believe to be accurate and complete in every respect. I understand payments approved by Sovereign will be made to the medical provider, or in the case of reimbursement payments will be made to the owner of the bank account provided with this claim form.