Important information

This brochure is not a contract of insurance. The precise terms and conditions of the plan are specified in the policy contract.

A Policy Wording in relation to AXA Personal Mobility Protect is available and may be obtained from AXA Insurance Private Limited and the participating distributors’ offices. You should read the Policy Wording before deciding whether to purchase the policy. This brochure is published for general information only. You may wish to seek advice from a qualified adviser before making a commitment to purchase this product. in the event that you choose not to seek advice from qualified adviser, you should consider whether the product in question is suitable for you. It is usually detrimental to replace an existing personal accident insurance policy with a new one. A penalty may be imposed for early policy termination and the new policy may cost more or have less benefits at the same cost.

The insurance policy featured in this brochure is protected under the Policy Owners’ Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC). Coverage for your policy is automatic and no further action is required from you should you buy the policy. For more information on the types of benefits that are covered under the Policy Owners’ Protection Scheme as well as the limits of coverage, where applicable, please visit the AXA website at www.axa.com.sg or visit the GIA or SDIC websites (www.gia.org.sg or www.sdic.org.sg).

All information stated in the brochure is correct as of 18 February 2018.

Contact Us1800 880 4888 (Singapore) 65 6880 4888 (International) customer.care@axa.com.sgaxa.com.sg

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Payment of Premium

Please choose only ONE payment mode:

Cash/Nets Make your payments at our AXA Customer Centre at AXA Tower during office hours (Monday to Friday, 9.00am to 5.30pm). Please do not send cash by post.

Cheque Crossed and made payable to AXA Insurance Pte Ltd. Please indicate the Policyholder’s name, NRIC, Product and Contact Number clearly on the back of the cheque. Please do not send post-dated cheques. Bank : __________________________________________ Cheque Number :__________________

Credit Card/ Debit Card Choose one of the following:

by downloading the AXS app to make payments online; or

at AXS stations located island-wide; or

via online where AXA will send a payment link to the Email Address stated in this application form.

In order to enhance the security of your credit card data, please note that we do not require credit card authorisation forms or your full credit card number via phone.

Declaration

1. I confirm that the information I have provided is my personal data and, where it is not my personal data, that I have the consent of the owner of such personal data to provide such information. By providing this information, I understand and give my consent for AXA Insurance Pte Ltd (“AXA”) and their respective representatives or agents to:

a. Collect, use, store, transfer and /or disclose the information, to or with all such persons (including any member of the AXA Group or any third party service provider, and whether within or outside of Singapore) for the purpose of enabling AXA to provide me with services required of an insurance provider, including the evaluating, processing, administering and/or managing of my or our relationship and policy(ies) with AXA, and for the purposes set out in AXA’s Data Use Statement which can be found at: http://www.axa.com.sg (“Purposes”).

b. Collect, use, store, transfer and/or disclose personal data about me or us and those whose personal data I or We have provided from sources other than myself or us for the Purposes.

c. Contact me or us to share information about products and services from AXA that may be of interest to me or us by post and e-mail and ( ) By telephone ( ) By fax ( ) By text message

2. By submitting this application, I declare on behalf of all persons covered under this Policy that the above answers are complete and true and agree that they shall form part of my application which shall be the basis of the contract of insurance.

3. I understand that this Policy shall only be effective following premium payment and subject to the acceptance and approval of this application by AXA.

Signature of Client (for and behalf of all persons to be insured)

Date (DD/MM/YYYY) Name of Advisor/Account code

AXA PERSONAL MOBILITY PROTECT An insurance plan that covers you against accidents and liability to third parties while riding your Personal Mobility Device

Ride with

confidence

Accidental Death Benefit Provides S$200,000 lump sum payout in the event of death due to an accident.

Permanent Disablement Benefit Provides up to S$200,000 in the event you are permanently disabled due to an accident.

Medical Expenses Reimbursement Get reimbursed for up to S$2,000^ in medical expenses for injury due to an accident.

Personal Liability Cover If you accidentally injure someone or damage someone's property while riding a PMD, we have got you covered up to S$500,000* for personal liability against third parties.

Ride confidently with comprehensive coverage

Get around confidently and enjoy your rides, knowing that you have comprehensive cover for accidental injuries to yourself or others while riding a PMD — all at an affordable premium.

AXA Personal Mobility ProtectPersonal Accident Insurance Application Form

Important Notes:1. Personal mobility device (PMD) refers to an e-Scooter that is registered with the Land Transport Authority (LTA).2. Coverage is for use for leisure purpose within Singapore only and if the Insured Person is at least 21 years old and no more than 65 years old at the inception of policy.3. In the event of an accident, medical treatment must be sought in Singapore within 48 hours of the accident and up to 30 days thereafter.4. Police report must be made for injury to third party. 5. Damage and/or loss of PMD is not covered. For the full terms, conditions and exclusions of coverage, please refer to Policy Wording.

Note^ You pay the first S$200 per accident.# You pay the first $500 per accident.For the full terms, conditions and exclusions of coverage, please refer to Policy Wording.

Statement pursuant to Section 25(5) of the Insurance Act (Cap142) or any amendments to it, you must reveal all facts that you know, or ought to know, which may affect the insurance cover that you are applying. Otherwise, the insurance cover may not be valid.

Particulars of Policyholder

Name (Mr/Mrs/Ms/Dr):

Date of Birth: NRIC / FIN:

Mailing Address: Postal Code:

Mobile: Email Address:

Details of persons to be InsuredFull Name as in NRIC Gender NRIC / FIN Nationality Date of Birth Premium (S$)

M / F

M / F

M / F

Total Premium (inclusive of GST): S$

Insurance CoveragePeriod of Insurance: 12 months from (dd/mm/yyyy):

This is a Personal Accident policy and benefits will only be payable when an accident occurs whilst the insured is riding (including whilst boarding and alighting from) a LTA-registered e-Scooter.

Coverage Maximum Payable Limit (SGD)Accidental Death Pays the benefit sum in the event of death caused solely by an accident whilst riding the PMD

$200,000

Permanent Disablement Pays the benefit sum in the event of permanent disablement caused solely by an accident whilst riding the PMD

$200,000

Accidental Medical Expenses Reimburses for the medical treatment incurred within 48 hours caused solely by an accident whilst riding the PMD

$2,000 per accident (You pay the first $200 per accident)

Personal Liability Pays for the legal liability in the event the insured accidentally injure someone or damage someone’s property whilst riding the PMD (Up to $1,000 for damage to personal property)

$500,000 per policy year (You pay the first $500 per accident)

Annual Premium (inclusive of 7% GST) $76.00 per person

78%believe they make sidewalks more dangerous

77%feel they increase sidewalk congestion

72%think they contribute to more accidents

Personal Mobility Devices (PMDs) in Singapore

AXA Mobility Survey was conducted to understand public sentiment toward the changing mobility landscape with the introduction of PMDs and bike-sharing service and the perception of road safety in Singapore. Here are what Singaporeans think about bike-sharing and PMDs:

74%think they make commuting easier

60%believe they promote healthier living

38%feel they make roads less congested

Watch your speed and go slow around others.

Always give way to pedestrians.

Walk your e-scooter in crowded areas, at zebra-crossings and at traffic light junctions.

Tips for Riding Alongside Pedestrians

But

Singaporeans embrace the convenience of bicycles and PMDs, but require greater awareness of rules and regulations.

Source: AXA Mobility Survey 2018