Death Claim

I hereby warrant and declare that the foregoing answers and statements are true to the best of my knowledge and belief, and that I have withheld no material fact from RP Assurance. I agree that the written statement, and affidavits of all documents submitted in support of this claim shall constitute and are hereby made a part of this claim. I further agree that the supply of this form or of any other forms supplemental hereto by RP Assurance shall not constitute an admission by it that there is any assurance in force on the life in question or a waiver of any of its rights or defence in law. I acknowledge and agree that any benefits payable in respect of this claim shall be forfeited if I, or anyone acting on my behalf or with my knowledge and consent, have knowingly withheld any material fact or submitted any false information in respect of the claim. I further agree that upon payment of the benefits hereby claimed, RP Assurance shall be discharged from all liability in respect of such benefit. I hereby authorise Real People Assurance Company Limited and/or its holding company or any of their affiliates or subsidiaries to request information with any registered credit bureau or other entity holding information as may be reasonably required to assess the validity of the claim instituted by me. If any false statements are made, or if any inaccurate or false Information is given by you in in your forms or ancillary documentation, which may lead to your claim being approved, or any fraudulent declaration is made by you, your cover will be void and no benefits under the policy will be payable and all premiums paid will be forfeited. In the event that a claimant is incapable of managing his/her own affairs, an appointment of a curator bonis will be required in order for RP Assurance to further assess the claim.