Health Information Consent
We may use the health information which you provide about yourself or other persons now when assessing claims which you or those other persons later make on an insurance policy. You represent and warrant that you have obtained from any persons whose health information you provide to us their consent to us using their information for the purposes described here. We will comply with the terms of our Privacy Policy. You do not have to provide us with the following consent, and you may withdraw it at any time, but if you do not provide it, or choose to later withdraw it, that may affect our ability to offer you an insurance policy (or lead to the cancellation of an existing policy) or our ability to process any future claims.
I consent to Chubb using my health information as set out above.
Signed ________________________________
Name (_________________________________)
Date _________________________________