ae es Last Name st Name "Mico Narre Age | Date oF Bi Piace oft ‘Gender WAiaionaity —¥ Heiohi Weight Viel Stats Cwiowed Dale ‘Binin Bibs | Cisinglo O'Separated CiFemale hem Bho | Siaries Dworoed Adress Praca of Work Eireboyer ra Era AEBS [Pim Prone Fame Prone [ye Mar Has the Applicant previously exfferad heart ailack, or boon diagnosed and currenty sufening tom any type of cancer beyond | Stage'| congasive haart falure, advanced or sovere types of Iver or ladney talure or any other condition that causes progrestive ireversite uncon or physical dsatity or an iiness or condition thal requires traquert hospital confinement of lt least tee (3) mas a your? o Have you ever suffered ftom or sought mecical treatm ‘rok, eplepsy. fang attacks or any cscrder of mental or nervous systorn? asthma, bronchitis or any lung problem? ‘Shoat pain, numbness or woakness of extremities or ary haart dsorser? hryperacity, leer, chic or recur arthea, or ary other disorder ofthe digestive system? ‘Gabates,thyrod and complestions tothe eyes, kney, Iver ard hear”? ‘ney diseases or urinary system disorders such as, bicod nthe urine r kidney stones? ‘hourat fever. artis, gout or ary joint or bone csordors? ‘cancer, tumor, enlarged gland or tiood csorders? Unexplained recurrent o persistant lever or skin cisordor? ‘any Sexually transmitted loease (auch as syphilis or gonorrhea) or viral disease (e.g. hepatitis Bor AIDS)? any other liness, injury, ésabaty not mentioned above? ‘3. Have you ever boon diagnosed as suffering irom hypertension? Have you ever undergone any surgical operations oF Invasive procedures fr the last 2 years? ‘5. Have you ever undergone laboratory tast or other diagnostic exarrinations? 8. _ Any hospital confinement or surgical procedure being contemplated”, 77. ave you ever received treaiment with any blood products or undergone ood transfusion? a a. Hl oooeoEoHs o re-Bol- Rope {Any other disease oF complaint not mentioned above? Except as presoibed by a physician, Rave you ever used shabu, cocaine, heroin, marusna or other narcotics? ‘Do you smoke or have you over smoked more than 10 exgarettes por day” Bo you take of have you ever taken more than six urs of sloahol per day 1 url= 1/2 pint beeriager, 1 standard {lass of wine, 1 pub measure of spr? 12, fre you currently Iaking medicabons, rare you under medical care of any nd? 18 Forfemales: “Are you pregnant? ‘Any compleatons vslh pregnancy? +14 Doyouhave anyother application for or reinstaloment of fe insurance peneing? tyes, qlve details. [ Wh 800 Lie Assurance Compary. ne ‘Wit otfier companies e P | Dota of Vox" anawors Please indicate question number. Use back page, necessary) Dopo cposcsoecsseoooesEs BO Booo8 cdopopoo! ‘DISCLOSURE accordance wi the Treurarcs Commissions CGIGr Later No. 2076-4, your medical oration wil be uploaded to = Medica! Information Daiabase accessible oie Insurance companies forthe purpose of enhancing rék ascessmont and preventing (aud. Once upoaded al Ite insurance companies wil only have inited access 10 your formation in afer 9 protect your Nght fa privacy im accordance with law. A copy Of ‘Greular Lefer No, 2016.64 may be accessed a he Insurance Commission's websile ai wesw insurance. gov |, the above-named Applicant, declare tha, to the best of my knowledge and belie, the above answers and statements are true, complete land conectly recorded; and agree that this application, if approved, shall be the basis for delivery, change or reinstatement of insurance coverage. | possess sound health and am ablo to perform the normal activities in the pursuit of my livelihood. | understand and agree that the insurance fseuad on this application ie basod on the truth of the foregoing representations and is subject to the provisions of the Group Life Inaurance Master Policy issued by BDO Life Assurance Compary, Inc. (BDOLAC) who reserves the right to reject the application or rescind the insurance if there was failure on my par, whether intentional or unintentional, to dieciose material information pertinont to the insurance ‘applied for. agree that BDOLAC shall incur no liabilly by reason of this application or for any cash paid or satloment made in connection therewith, uni this application has been approved by BIDOLAC. I hereby authorize - even abroad - any physician, hospital, elie, insurance company or any other organization, institution, or person that has: ‘any record of me and my health to gWve to BDOLAG, its Parent Company, its Trust Companies and Subsidiaries, any and all information ‘about me with reference to my health, medical history, any hospitalization, advice, diagnosis, teatment, disease, or ailment or persona, financial, or occupational background for the purposes of underwriting (i applicable), claim assessment, claim setiement, coinsurance and reinsurance. | also consent to any personal investigation. A photographic copy of this authorization shall be as valid as the original Signed at : on ‘Signature Over Printed Name of Applicant ‘Signature Over Printed Name of Wiiness BDO Life Assurance Company, Inc. 1800 Corpatte Garr 795 Maka Avorue, Maka ny, ewe fara, Pa Customer Care Htine (62) ABB 10| Ter ia: (9S2) 8864100, 8864200 [Fax (682) 5280792