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Where applicable) with services required of an insurance provider, including the evaluating, processing, administering and/or managing my/our and/or the claimant s claims or the Policyholder Group Policy(ies) with AXA (as the case may be), and for the purposes set out in AXA s Data Use Statement which can be found at http://www.axa.com.sg ( Purposes ). Date: Date: Signature of Claimant.

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