Section A

Section B

Surgical intervention recommended by Doctor

hereby declare that all the information given above is true to my knowledge, and that I have neither retained nor concealed any information regarding the claim put forward. I am fully aware that all false declaration and/or non-disclosure of material facts shall render this claim null and void and will entail the termination of the contract

I authorise RPL Insurance Agency to contact my treating doctor in respect of any complementary information required in relation to my illness or treatment received in relation to the claim and as regards my medical history and also authorise that these information be communicated to RPL Insurance Agency.