‘COVERAGE / SUPPORTING DOCUMENTATION / CLAIM AMOUNT winor ‘in case of death of an insured Person, Repatriation (1) proof of cancellation of household registration of the Insurance Person or ‘ther relevant proofs or identity documents of similar natures (2) proof of household registration of the death beneticiary/beneticiaries or ‘other relevant proofs or identity documents of similar natures {3} a death certificate or other relevant documentation of similar nature issued by Hospfta or polices (4). Return ticket ofthe chit; (5) receipt for endorsement or refund of return air ticket of the child (if applicable; 2. the insured Person needs hospital treatment and is Confined to Hospitalized for more than ten (10) consecutive days due to Severe Bodily Injury, (1) medical record issued by a Hospital and the severe illness certification issued Qualified Medical Practitioners (2) Return ticket ofthe chit; {3} receipt for endorsement or refund of retum air ticket of the child (i applicable); ‘ANTI-FRAUD NOTICE ‘Good faith represents a fundamental principle underiying an insurance contract and any person suspected of insurance fraud will be subject to the following liabilities: 1. Criminal Labiity: Criminal activities of insurance fraud may be subject to punishment of criminal detention, imprisonment, fines oF penalties, or confiscation of property. The appraiser and/or certifier of an insured event who intentionally provides false supporting documents for any other person to.commit-an insurance fraud willbe punished as an accomplice for crime of insurance fraud. 2. Administrative Liability: Insurance fraud which does not constitute a crime may be subject to punishment of administrative etention within 15 days, fines or penalties up to RMBS,000.The apprater and/or certifier of an insured event Wwho intentionally provide false supporting documents for any other person to commit an insurance fraud will be subject to administrative punishments asthe case may be. 3. Civil Liability: In the event of non-disclosure, whether intentionally or due to gross negligence, the Insurer shall not be table for making any payment. DECLARATION & AUTHORISATION The undersigned hereby declare that to the best of my/our knowledge and belief, the above statements are fully and truly made and that I/we have read and fully understood the above “Anti-fraud Notice”. I/We understand that the furnishing of this form to ‘me/us, oF its preparation by any representative of AIG Insurance Company China Limited (the “Company”) or the acceptance or retention of the proof thereafter by the Company shall not constitute its waiver of any of the conditions of the policy. The undersigned authorize any physician, medical practitioner, hospital, clinic, potice authority, insurance ‘company or any other organization and institution that has any record or knowledge of my / the Insured’s health and medical history or any treatment, advice or accident details and that has been or may hereafter be consulted to disclose to AIG Insurance Company or its authorized Fepresentatives such information. This authorization shall bind my / the Insured’s successors and assigns and remain valid notwithstanding my / the Insured’s death or incapacity in so far as legally possible. A photocopy of this authorization shall be considered as effective and valid as the original. “The undersigned hereby authorize AIG insurance Company China Limited to disclose my information to a third party to comply with the minimum requirements of laws, including but not limited to the laws of People’s Republic of China. Signature of Claimant Signature of Guardian (if claimant is minor) ote 2O Joc 209L( bate 33