MENTAL HEALTH QUESTIONNAIRE

WARNING: IN PURSUANCE OF SECTION 25(5) OF THE INSURANCE ACT (CAP 142) REVISED EDITION 2002,
SINGAPORE, YOU ARE TO DISCLOSE IN THIS SUPPLEMENTARY QUESTIONNAIRE, FULLY AND FAITHFULLY, ALL
FACTS WHICH YOU KNOW, OR OUGHT TO KNOW, OTHERWISE THE POLICY ISSUED HEREUNDER MAY BE VOID.

Applicatione
Numb r :____________________________________

Name of Life Assured : ____________________________________

Name of Proposer (if other than Life Assured) : ____________________________________

1. State the onset date of the condition and the details of the symptoms you had.

_______________________________________________________________________________
2. State the exact diagnosis of the illness? __________________________________________

3. State the date/dates of onset (if more than 1 onset)? _____________________________

State the date of last attack _____________________________

4. Did the condition develop as a reaction to a particular circumstance? If yes, please elaborate.

_____________________________________________________________________________
5. Are you receiving treatment/medications currently? … Yes … No
If YES, please state the types of medications prescribed. _________________________________
If NO, please provide the date of cessation __________________________________
6. Were there any suicidal tendencies or actual suicide attempts? If yes, please give details.

______________________________________________________________________________
7. Have you been seen by a specialist? … Ye s … No
If YES, please provide the name & address of the doctor.
_______________________________________________________________________________
8. Have you been hospitalised for depression or any other mental condition during the last 5 years ?
Please provide details and dates.
_______________________________________________________________________________

I/We hereby declare that the foregoing statements are to the best of my/our knowledge and belief, true
and complete and that they shall form part of my/our Application for Life Assurance dated
_____________________.

________________________ ________________________
Signature of Life Assured Signature of Proposer
(if other than Life Assured)
Date: ____________________ Date: ____________________

AXA Insurance Pte Ltd (Company Reg. No. 199903512M)

8 Shenton Way #24-01 AXA Tower Singapore 068811
AXA Customer Centre #01-21/22 Tel: 1800 880 4888
Website: www.axa.com.sg

Page 1 of 1 Ver.Nov2017