Cigna Global Health Benefits Authorisation Form Member Name: FU FANG Cigna Membership Number. 20 136 472 (This number is shown on your Cigna membership card) | confirm that | authorise Cigna to provide access to my medical claims information upon request to the individual detailed below: Name: Maan f. Nillat Date of Birth: Match 20, 1940 Telephone Number: +63 417 3% 7504 Esmail address: aan viltor.cxt @nokia- sel com | understand that by providing authorisation, the above named individual will also have ‘access to claims information for any family members | have on cover. | have discussed the implications of this with all family members covered under the policy and they are happy for ‘the above name individual to discuss their claims information with Cigna. | also understand that | can retract this consent at any time by contacting Cigna, and must advise Cigna if there is any change in contact name or details. Member Signature: AE PUPANG Date: 4 December 2014 gna Le nsuarce Company of Europe SA-N. Branch Charcary House a Fe St choi ny. Suton. Srey ‘SUIT 118 regsteres in Belgum wit imted liabilty Srussels trade register ro. 0421 437 254), Averue ce ‘o00Stuase, Sep eutersedby fe tera Sen ot Glgum era nae s tae repunsory he Poured ‘Autnonty and Prudential Regulation Autnoriy. Detsls ebout he eer of cur regulation bythe Financial Conduct Authorty and Prudential Regulstn Authorty sre avalabe tom us en reqvest.