I hereby declare, agree and warrant that:

Any personal information provided on the Passenger Information page, or any other confirmation signed by me in conjunction with this application shall form the basis of the insurance contract are fully correct and/or complete and are made to PT Asuransi AXA Indonesia (hereinafter referred to as "the Company"). The Company acknowledge and agree that such information are Customer Data as well as Confidential Information belonging to the Customer. If the information given are not fully correct and/or complete, any policy issued may be void according to the Company's option.

Any personal information collected by the Company may be used and disclosed by the Company to individuals, service providers and organizations associated with the Company or any other selected third parties (within or outside of Indonesia, including insurance, reinsurance and claims investigation companies and industry associations) for the purpose of processing this application and providing subsequent service for this and other financial products and services, direct marketing and data matching, and to communicate with me for such purposes. I understand that I have the right to obtain access and to request correction to the Company's Customer Service Centre of any personal information held by the Company.

I hereby irrevocably authorize PT Tunas Sukses Mandiri (NusaTrip) and/or its affiliates to fully release any personal information collected or held by them to the Company for the purpose of this insurance.

I hereby irrevocably authorize any organization, institution or individual that has any records or knowledge of me/my insured family member(s) health and medical history and any treatment or advice to disclose such information to the Company. This information shall bind me/my insured family member(s), successors and assigns, and remain valid, notwithstanding my/my insured family member(s) death or incapacity.

The coverage applies only in the country of arrival and air travel cover is limited to the flight I purchased on Nusatrip website.

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