Policy Number

511 - 3336738

Application Number GV 31075-202010051128-3-02

Application for Life Insurance Variable Multiple Application of

(GUARANTEED ISSUE OFFER)

Accomplish the details and put “N/A” if not applicable. Print legibly using BLACK INK.
Any erasure should be countersigned by the Owner. This form must be filled out by the
Owner or by a person acting under the Owner’s direction and authority.
FOR OFFICE USE ONLY
Important Notes:
Date Received:
1. An Insurance is a contract of utmost good faith and the Proposed
Insured/Proposed Owner is required to disclose ALL material facts to the Time Received:
insurer. All answers to the questions stipulated in this questionnaire are the Receiving
basis of and are an inseparable part of the insurance policy. In case of doubt Dept./Office:
as to whether a fact is material or not, the fact should be disclosed.
2. Please do not sign on a blank form.
3. Please shade the circle to indicate your choice(s).

1. DETAILS OF PROPOSED INSURED

LAST NAME
BAUTISTA
Notes
FIRST NAME
LUCY MAE Please accomplish as
well the “Proposed Owner Details”
MIDDLE NAME section at the
back page if the Proposed
Owner is different from
SANTIAGO the Proposed Insured.

DATE OF BIRTH(YYYY/MM/DD) PLACE OF BIRTH Politically Exposed Person (PEP)

SEX CIVIL STATUS
is an individual who is or has
NUEVA ECIJA Male Female
1998/09/06 Single Married Widow Divorced/Annulled been entrusted with prominent
public positions in the Philippines
with substantial authority over
policy, operations, or the use or
allocation of government-owned
NATURE OF OCCUPATION/BUSINESS SPECIFIC OCCUPATION IDENTITY NO. (TIN, SSS or GSIS) resources; or a foreign state or
Nurse Passport No.: P0275904B international organization,
including heads of state or of
NATIONALITY government, senior politicians,
senior national, or local
ARE YOU AND/OR YOUR IMMEDIATE FAMILY A POLITICALLY EXPOSED PERSON (PEP)? Yes No Philippines government, judicial or military
(If yes, please specify government position/public office)
officials, senior executives of
government or state-owned or
IF WORKING ABROAD, STATE THE CITY/PROVINCE AND COUNTRY controlled corporations and
important political party
RESIDENCE/PRESENT ADDRESS officials.
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE
74 PUROK 7 BARANGAY STA RITA CABIAO NUEVA ECIJA 3107

Residence Address should

be a Philippine Address
PERMANENT ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS) (in reference to
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE Cross-Border Rule)

74 PUROK 7 BARANGAY STA RITA CABIAO NUEVA ECIJA 3107 Residence Address shall
be used as default mailing
address

BUSINESS ADDRESS
ZIP CODE Unless you are a bank
BUSINESS NAME/NAME OF EMPLOYER (Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province)
employee, Bank address
ST LUKES MEDICAL CENTER 279 E RODRIGUEZ SR QUEZON CITY METRO MANILA 1112 and contact information
should not be used

PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business

CONTACT INFORMATION
HOME PHONE NUMBER MOBILE NUMBER (Mandatory)
0 639663701073

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

0 BAUTISTA.LCYM@GMAIL.COM

SOURCE OF FUNDS/MONTHLY INCOME Answer this question only

if Proposed Insured is the
Salaries/Php 35000.00 Income from business/Php Savings/Php 100000.00 same as the Proposed Owner

Maturing Investment/Php Others:

IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX RESIDENT? No Yes US TIN/SSN:

(If yes, please provide US TIN/SSN)

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Application for Life Insurance Application Number GV 31075-202010051128-3-02

2. DETAILS OF PROPOSED OWNER (If different from Proposed Insured)

LAST NAME
Notes

FIRST NAME Accomplish only if

Proposed Owner is
different from Proposed
Insured.
MIDDLE NAME
Politically Exposed Person
(PEP)
is an individual who is or has been
DATE OF BIRTH(YYYY/MM/DD) PLACE OF BIRTH entrusted with prominent public
SEX CIVIL STATUS positions in the Philippines with
substantial authority over policy,
Male Female Single Married Widow Divorced/Annulled operations, or the use or allocation
of government-owned resources;
or a foreign state or international
organization, including heads of
state or of government, senior
NATURE OF OCCUPATION/BUSINESS SPECIFIC OCCUPATION IDENTITY NO. (TIN, SSS or GSIS) politicians, senior national, or
local government, judicial or
military officials, senior executives
of government or state-owned or
NATIONALITY controlled corporations and
important political party officials.
ARE YOU AND/OR YOUR IMMEDIATE FAMILY A POLITICALLY EXPOSED PERSON (PEP)? Yes No

(If yes, please specify government position/public office)

IF WORKING ABROAD, STATE THE CITY/PROVINCE AND COUNTRY

RESIDENCE/PRESENT ADDRESS
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE
Residence Address should
be a Philippine Address
(in reference to
Cross-Border Rule)
PERMANENT ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)
Residence Address shall
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE
be used as default mailing
address

BUSINESS ADDRESS
BUSINESS NAME/NAME OF EMPLOYER (Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE

PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business

CONTACT INFORMATION
HOME PHONE NUMBER MOBILE NUMBER (Mandatory)

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

The Contingent Owner will
automatically become the
new Owner of this policy in
the event that the Owner
RELATIONSHIP OF PROPOSED OWNER CONTINGENT OWNER UPON DEATH RELATIONSHIP OF CONTINGENT
predeceases the Insured
TO PROPOSED INSURED OF OWNER OWNER TO PROPOSED INSURED while this Policy is in force.
If the owner has not
appointed a Contingent
Owner, the Insured shall
automatically become the
SOURCE OF FUNDS/MONTHLY INCOME new Owner of this Policy in
the event that the Owner
Salaries/Php Income from business/Php Savings/Php predeceases the Insured
while the policy is in force.
Maturing Investment/Php Others: Designation of a
minor as Contingent Owner
is discouraged.
IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX RESIDENT? No Yes US TIN/SSN:
(If yes, please provide US TIN/SSN)

BENEFICIAL OWNER (If any)

Beneficial Owner refers to
the owner/controller of the
policy owner as well as to
the beneficiary to the policy
contract. It also refers to a
Full name, Present address, Date and place of birth, Nature of work, Sources of funds natural person who
ultimately owns or controls
the account and/or the
3. DETAILS OF THE COMPANY (IF OWNER IS COMPANY) person on whose behalf a
transaction or activity is
being conducted. It also
includes those persons who
FULL BUSINESS/COMPANY NAME FULL NAME OF AUTHORIZED SIGNATORY has ultimate effective
control over a legal person
or arrangement.

NATURE OF BUSINESS FULL NAME OF AUTHORIZED SIGNATORY

*Authorized signatory/ies will be asked to provide required additional information

CONTACT INFORMATION OF AUTHORIZED SIGNATORY

MOBILE NUMBER (Mandatory) BUSINESS ADDRESS

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

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Application for Life Insurance Application Number GV 31075-202010051128-3-02

4. BENEFICIARY DESIGNATION Notes

*TYPE OF IRREVOCABLE Surviving Beneficiaries in

NAME PRESENT PLACE OF DATE OF NATURE OF RELATIONSHIP BENEFIT BENEFICIARY (Please shade if the same classification
(Last, First, Middle Name) ADDRESS BIRTH BIRTH WORK TO PROPOSED % (optional) Irrevocable will equally share in the
Beneficiary) benefits.
INSURED Primary Secondary

74 PUROK 7 BARANGAY STA RITA NUEVA

House Designation of a minor as
BAUTISTA, LUCILA 1972/12/12 wife/unemploye Parent 50 Irrevocable beneficiary
CABIAO NUEVA ECIJA ECIJA
d
is discouraged.
74 PUROK 7 BARANGAY STA RITA NUEVA Secondary Beneficiaries
BAUTISTA, RICHARD 1972/03/18 Engineer Parent 50
CABIAO NUEVA ECIJA ECIJA
are entitled to the benefits
if no Primary Beneficiary
BAUTISTA, JOHN CHARLIE
74 PUROK 7 BARANGAY STA RITA NUEVA
1999/09/14 Engineer Sibling 50 survives
CABIAO NUEVA ECIJA ECIJA
When policy owner (PO)
74 PUROK 7 BARANGAY STA RITA NUEVA designates a revocable
BAUTISTA, CYRILE MAE 2005/03/21 Student Sibling 50
CABIAO NUEVA ECIJA ECIJA beneficiary, the PO may
change the policy details,
including its beneficiaries,
any time. However, when PO
5. BASIC PLAN DETAILS designates irrevocable
beneficiary, PO may not
change the details of the
SINGLE PREMIUM PLAN NAME policy, without prior consent
CURRENCY
of said irrevocable
Peso Dollar 2,500.00 Asset Master GIO beneficiary.

Single Premium refers to a

PURPOSE OF THE INSURANCE APPLIED FOR: single one-off payment that
Income protection Retirement planning Business continuation/ Keyman insurance Fringe benefit covers the entire cost of the
Policy.
Children’s protection Education funding Outstanding mortgage loan Estate planning

Savings Others (Beneficiaries are preferably “irrevocable”) Credit card payment is NOT
allowed for Single Premium
policies

6. DETAILS FOR VARIABLE INSURANCE All fund allocations should

total to 100%

FUND NAME % ALLOCATION FUND NAME % ALLOCATION

1. Global Advantage Fund 100 4.

2. 5.

3. 6.

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Application for Life Insurance Application Number GV 31075-202010051128-3-02

7. REPLACEMENT OF EXISTING LIFE INSURANCE POLICIES

Replacing an existing life insurance with a new one is in most cases disadvantageous as you might be confronted with a loss of financial
benefits or higher premiums in the new plan. Before you decide to replace a policy, ensure that you have full information of both policies.

Is this Policy replacing another policy with AXA or any other insurance company? Yes No

8. DECLARATIONS AND AGREEMENT:

I/WE UNDERSTAND, DECLARE AND AGREE THAT:
1. Before signing this Application, I/we have read the same carefully and the questions were fully explained to me/us in a language/dialect which I/we understand. I
have read and understood all declarations and agreements which are hereby given and made willingly and voluntarily and with full knowledge of my rights under the
law.
2. The answers or statements made in this Application and those that I/we made in the Full Medical Report and any other document attached thereto, are complete, true
and correctly recorded and shall form part of and be the basis of the insurance contract herein applied for. Failure to make a full disclosure renders the contract
voidable.
3. I/We understand that the designated Contingent Owner (if any) will automatically become the new Owner of this policy or in the event that I/we have not designated
a Contingent Owner, I/we understand that the Insured shall automatically become the new Owner of the Policy in the event that the Owner predeceases the Insured
while the Policy is inforce.
4. I/We declare that I/we am/are aware of the consequences of a minor beneficiary designation as follows: (a) that a minor, if designated irrevocable, is still unable to
give a valid consent to any transaction on the policy; where such consent is required, the minor would need representation by a guardian appointed by the court when
transactions like policy loan, surrender, changes in benefit, etc. are applied for under the policy: (b) when a death claim is filed under the policy, whether the minor is
a revocable or irrevocable beneficiary, a court appointed guardian and guardian’s bond will be required.
5. All the information I/we provided on this application form are to the best of my knowledge true and correct.
6. Any of my/our personal information collected or held by AXA Philippines (whether contained in the application/s or otherwise), may be used in connection with
matching for whatever purpose with such other personal information and/or may be used, stored, disclosed, transferred (whether within or outside the
Philippines) to such persons as AXA Philippines may consider necessary, including without limitation but not limited to any of its affiliated or related companies,
or any individuals/organizations/corporations/entities associated with AXA Philippines:
a. to process and deal with my application/policy;
b. to provide all services related to my application/policy, to promote other products/services by AXA Philippines and its affiliated or related
companies/entities, and to process my information for product development and for marketing purposes;
c. to communicate with me for any purpose and/or to comply with the laws of any applicable jurisdiction.
I/We understand that we have the right to access our personal information at any time; correct or rectify any information collected or held by AXA Philippines which
are inaccurate, false, or incomplete; object in case of any unauthorized collection; erase or block information which is incomplete, outdated and false; and such other
rights as may be available under the Data Privacy Act.
7. I/We understand that AXA Philippines shall use my/our personal information to evaluate and assess my/our application and need for life insurance and investments,
as well as to service any of my/our policies and needs including the evaluation of any future claims. I/We also authorize AXA Philippines to disclose to any person or
entities providing services on AXA’s behalf consistent with the purpose for which the information was obtained.
8. I understand that notices related to my policy may be sent to me through mail, email or SMS in the mailing/email address/number I provided above.
9. I/We declare that I/we have informed AXA Philippines of all my/our citizenships, residencies and tax residencies, and provided AXA Philippines with my/our
TIN, GSIS or SSS number(s). I/We agree to promptly update AXA Philippines of any changes to said information. I/We authorize AXA Philippines to disclose my/our
personal information to any government or tax authority (within or outside the Philippines) for the purposes of ensuring AXA’s compliance with applicable laws and
regulations.
I/We agree that AXA Philippines shall have the right to: (a) require the claimant(s) and/or payee(s) of the Policy to provide AXA Philippines with their above-
mentioned personal information and/or sign such documents as AXA Philippines may reasonably require; (b) and disclose said personal information to any
government or tax authority (whether within or out of the Philippines) for the purposes of AXA's compliance with applicable laws and regulations. If I/we fail to any
of the above-mentioned acts, I/we agree that AXA Philippines may provide my/our personal information to such government or taxation authority(ies) to comply
with the applicable laws and regulations.
10. The amounts invested have been declared to relevant tax authorities and none of it was derived, directly or indirectly, from illegal activities or sources and/or tax
evasion. If required by the proper tax and/or other governmental authorities, AXA Philippines may, in its discretion, disclose certain information about me/us or
about my policy.
11. I/We hereby authorize any person, physician, clinic, hospital, insurance company, or other organization, insurance association, institution, that has any record or
knowledge of my/our health and/or financial information to disclose or release to AXA Philippines or its authorized companies and their affiliates any medical
information sharing facility of the insurance industry, or any government agency requiring such, for any legitimate purpose, including underwriting and
administration of insurance coverage and claims.
12. I/We authorize AXA Philippines to request and obtain from third parties, whether government agencies or private entities, any information concerning me/us
relevant to this application, including medical or financial information.
13. There shall be no contract of insurance unless and until a policy is issued on this Application and the full first premium of the basic life insurance and any special
benefit applied for, according to the mode of payment specified in answer to Part 7, is actually paid during the lifetime and good health of the Proposed Insured.
14. I/We have read and fully understood the Life Insurance Proposal (or the illustration of benefits) for the policy applied for.
15. An electronic copy of this application shall be binding to me/us and shall be considered, for all intents and purposes, as originally signed document. I/We will inform
the Company of any inaccuracy or error in my/our personal data as soon as possible, and I/we understand that absent any request for correction within a reasonable
period, the Company shall rely on the electronic copy exclusively.
An electronic copy of the policy contract shall be sent to the Owner’s declared email address by default. Upon request and payment of reasonable fee, a hard copy of
the policy contract may be delivered to the nearest AXA Philippines Service Center for pick up by the Owner or his/her representative or directly to the Owner’s
mailing address, whichever is preferred.
My/Our electronic submissions shall constitute my/our intention to apply for this Policy and be bound by the terms and conditions relating to all transactions
undertaken, including but not limited to receipt of notices, presentation and purchase.
16. I/We understand that Inflation Index Endorsement (IIE), if included in the Life Insurance Proposal, will be applied at each Policy Anniversary. I further understand
that IIE means that with no further proof of insurability and with a minimal additional premium, my insurance protection will be increased to ensure that the basic
sum insured will be maintained against inflation. I/ We also understand that I can choose not to avail of IIE by informing the Company via email, call or advise
through my/our distributor.
17. I/We understand that Inflation Index Endorsement (IIE), if included in the Life Insurance Proposal, will be applied at each Policy Anniversary. I further understand
that IIE means that with no further proof of insurability and with a minimal additional premium, my insurance protection will be increased to ensure that the sum
insured will be maintained against inflation. I/ We also understand that I can choose not to avail of IIE by informing the Company via email, call or advise through
my/our distributor.
18. Other agreements pertaining to Variable Life Insurance products:

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Application for Life Insurance Application Number GV 31075-202010051128-3-02

a. My/Our Fund Allocation instruction, if applicable, is based on my/our own judgment and I/we have not relied on any advice provided by the
Advisor/FE;
b. I/We am/are fully aware that, if applicable, relevant policy charges, e.g. bid-offer spread, premium charge, asset management charge, will be imposed
on the policy that will be issued;
c. I/We fully understand that a variable life insurance product involves risk. Value of units in Investment Funds may rise or fall. The benefits payable
under such product are linked to the performance of the Investment Funds according to my Fund Allocation Instruction;
d. I/We fully understand that if this application is cancelled by written notice, signed and sent by me/us directly to and received by the New Business and
Underwriting Department of AXA Philippines before it is approved, I/we can refund all the premium deposits paid by me/us and received by AXA
Philippines. If such notice is received by the New Business and Underwriting Department of AXA Philippines after the application is approved, the
amount of refund shall be equal to the market value of its units including initial charges; and
e. I/We understand that I have the right to cancel the policy to be issued during the cooling-off period provided therein and obtain a refund equal to the
market value of units including the initial charges thereof by giving a written notice and returning the policy. Such notice must be signed and sent by
me/us directly to and received by Customer Experience of AXA Philippines within 15 days from my/our receipt of the policy.
19. In the event of the Insured’s death prior to his/her attaining the age of four (4) years and six (6) months:
a. the amount payable under the Policy shall be in accordance with the following schedule:
Age at Death Amount Payable (Variable Life Policy) Death Benefit Payable
(nearest birthday) (Traditional Life Policy)
Less than 6 months 50% of the Sum Insured, or the Account Value, whichever is higher 50% of the Sum Insured
1 year 60% of the Sum Insured, or the Account Value, whichever is higher 60% of the Sum Insured
2 years 70% of the Sum Insured, or the Account Value, whichever is higher 70% of the Sum Insured
3 years 80% of the Sum Insured, or the Account Value, whichever is higher 80% of the Sum Insured
4 years 90% of the Sum Insured, or the Account Value, whichever is higher 90% of the Sum Insured

b. If the Guaranteed Insurability Endorsement is attached to the Policy, the amount payable shall be the Death Benefit applicable in the Guaranteed
Insurability Endorsement, provided that the Insured’s death is due to causes other than a Covered Injury as defined in such endorsement.
c. The total amount of Death Benefits payable from the Policy and other in force policies and/or supplementary contracts issued by AXA Philippines shall
be subject to the maximum aggregate juvenile limit set by AXA Philippines and prevailing at the time the Policy was issued. Should the total Death
Benefits payable from the Policy and from all other in force policies and supplementary contracts issued by AXA Philippines covering the Insured exceed
the limit, then the benefit under the last policy(ies) or supplementary contract(s) which gave rise to the excess shall be correspondingly reduced and a
proportionate refund of the Premiums paid on such portion of the benefit shall be made to the Owner, without interest.
d. Benefits will still be subject to the Minimum Death Benefit as stated on the variable life insurance contract which will be issued to you. For a single
premium variable life insurance contract, this is equal to 125% of Single Premium paid, plus 125% of each subsequent top-up premiums, if any, less
125% of each partial withdrawal, if any. Additionally, for a regular-pay variable life insurance contract, this is equal to 500% of the annual premium
paid, plus 125% of each subsequent top-up premiums, if any, less 125% of each partial withdrawal, if any.

9. TELEPHONE UNDERWRITING AUTHORIZATION

I/We, hereby permit AXA Philippines to call me/us to clarify or gain further information regarding any matter pertaining to the assessment and processing
of my/our application for life insurance.

I / We understand that:
• I am/we are required to be truthful to the best of my/our knowledge
• The call is recorded and will take a few minutes of my /our time
• My/our answers will be binding and shall form part of the basis of my/our application for life insurance
• The result of the call will be documented and a copy of which, shall be attached to the policy contract.

I / We may be contacted at any of the contact numbers declared in the application form.

During office hours (8 am-5 pm) Others, please specify

10. REQUEST FOR DIRECT CREDIT TO BANK ACCOUNT

Policy No.: Account type: Bank Name:

Peso account Dollar account Metrobank Others:

Branch Name: Swift Code (for Non-Metrobank) Account Number of payee:

Account Name of payee: Relationship to owner

Spouse Child Parent Sibling

1. I declare that the proceeds of this application/policy once deposited to the account aforementioned shall be equivalent to payment to me directly of the same
and I shall render AXA Philippines, its successors-in-interests and assigns, including its directors, officers, employees and agents, free and harmless from
any further claim, demand or action whatsoever, which in law or equity I ever had, now have, or which I, my successors and assigns hereafter may have
under this said application/policy.
2. I declare that in the event the account aforementioned is owned by person other than me, the account owner is my relative and that I had sought his/her
consent to use his/her account to facilitate the payment to me of the proceeds of this application.
3. I understand that should the proceeds be credited to a non-Metrobank account, corresponding fees shall be charged to my account.
4. I/We, the undersigned, also take full responsibility in the accuracy of the account name and number indicated above. Should there be any error(s) in the
information, I/We understand that this will result to delays in the crediting of the policy proceeds and I/We shall bear the consequences.
5. Before signing this declarations and agreements, I have read and understood all declarations and agreements which are hereby given and made willingly and
voluntarily and with full knowledge of my rights under the law.

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Application for Life Insurance Application Number GV 31075-202010051128-3-02

**PLEASE DO NOT SIGN ON A BLANK FORM

Date of Signing: Place of Signing:

LUCY MAE BAUTISTA

Signature (Proposed Insured) Signature (Proposed Owner)

**(If this form was filled out by an Advisor/FE) I certify that I have acted under the direction and authority of the
Owner and that the Owner and/or Proposed Insured signed this Application Form in my presence.

Name of Advisor/FE: JUNIA, ABIGAIL GOMEZ Name of Advisor/FE:

Code: Code:

542004 4 31075

Signature: Signature:

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Application for Life Insurance Application Number GV 31075-202010051128-3-02

11. DISTRIBUTOR’S DECLARATION

I ensure that I, as the distributor, have guided the client in completing all relevant and necessary information to assist the Company in assessing the application. I further
declare that:
1. The information provided by the client in the application form are accurate and complete;
2. I/We also certify that I/we saw the Proposed Insured (and Owner, if applicable) and have verified his/her identity at the time of signing this application;
3. I shall make known to the Company any and all factors which, if known to the Company, may result in an applicant receiving rated or no coverage at all; and
4. Any additional information that shall be required by the Company in order to determine any particular application shall be provided on a timely basis.

Name of Advisor/FE: JUNIA, ABIGAIL GOMEZ Name of Advisor/FE

Signature: Signature:

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Application for Life Insurance Application Number GV 31075-202010051128-3-02

Application Number GV 31075-202010051128-3-02

TEMPORARY LIFE INSURANCE CERTIFICATE

There is temporary insurance on the life to be insured beginning on the date of signing by the Proposed Insured/Owner of the Application form bearing the same serial
number as this certificate, if all the following conditions are met: (1.) The first modal premium has been paid with the Application for which a Temporary Receipt is
issued; and (2.) All other required questions of the Application form are answered completely and truthfully. All conditions under this certificate are subject to the
Provisions of the Policy the Proposed Insured and/or Owner has applied for.
LIMITATION ON AMOUNT OF INSURANCE
The insurance benefit on the death of the life insured pursuant to this certificate is the amount which AXA Philippines would have paid had the Policy applied for been
issued. AXA Philippines shall in no event pay, subject to the imposition of juvenile lien whenever applicable, no more than One Million Pesos (PhP1,000,000) or the
equivalent in US Dollars, based on the prevailing exchange rate at the time of death of the Proposed Insured. The maximum amount of PhP1,000,000 includes any
accidental death benefit, under all Temporary Life Insurance Certificates inforce in respect of the Proposed Insured. However, if the insurance benefit paid for by the
Proposed Insured exceeds the said maximum, the amount of excess premium, which will be determined proportionately to the Policy applied for, will be refunded. The
insurance benefit will be prorated among all the Temporary Life Insurance Certificates inforce on that Proposed Insured.
TERMINATION OF TEMPORARY LIFE INSURANCE COVERAGE ON THE LIFE INSURED WILL BE THE NEAREST OF THE FOLLOWING:
(a) The date a termination notice is sent by AXA Philippines to the Applicant;
(b) The date the policy is issued as a result of the Application being approved;
(c) The date of termination as requested by the Applicant;
(d) The date of death of the Proposed Insured; and
(e) Sixty (60) days after signing this Application.
SUICIDE: If the life insured dies by suicide, the pertinent provisions of the Insurance Code shall apply. Where no insurance money is payable, the amount paid with
the Application will be refunded. No Advisor/Financial Executive has the authority to modify the terms of this Certificate.

IMPORTANT NOTICE
The Insurance Commission, with offices in Manila, Cebu and Davao, is the government office in charge of the
enforcement of all laws related to insurance and has supervision over insurance providers and intermediaries.
It is ready at all times to assist the general public in matters pertaining to insurance. For any inquiries or
complaints please contact the Public Assistance and Mediation Division (PAMeD) of the Insurance Commission
at 1071 United Nations Avenue, Manila with telephone numbers
+632-85238461 to 70 and email address publicassistance@insurance.gov.ph.
The official website of the Insurance Commission is www.insurance.gov.ph.

MAMGXXEXGIO-1118 8 of 19
 Asset Master
Policyowner / Insured:
LUCY MAE SANTIAGO BAUTISTA, Age 22, Female

Dear LUCY MAE,

Thank you for choosing Asset Master, a single-pay, investment-linked insurance plan that will help you create a lasting legacy for the coming
generations. With a one-time payment, you can start building a global portfolio of investments.

Plan Summary
Your One-Time Investment USD 2,500.00
Guaranteed Insurance Coverage USD 3,125.00
Living Benefit on the 10th policy year*
Assumed fund growth rate of 3.00% USD 3,250
Assumed fund growth rate of 7.75% USD 5,093
Assumed fund growth rate of 8.00% USD 5,212
*The rates of return shown above, which are approved by the Insurance Commission, are for illustration purposes and they do not guarantee future performance. The actual return may differ based
on actual market performance on valuation date.

Your Plan Benefits

1 Build your legacy

Get guaranteed life insurance of at least 125% of your one-time payment when no partial withdrawals are made from your
account.

Choose how you want to build your legacy with a wide variety of investment funds that give
you unparalleled control over your investments and are tailor-fitted to your risk profile

Build a truly diverse global portfolio with the AXA investment funds

This is not a deposit product. Earnings are not assured and principal amount invested is
exposed to risk of loss. This product cannot be sold to you unless its benefits and risks have
been thoroughly explained. If you do not fully understand this product, do not purchase or
invest in it.
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

2 Maximize your investment

Get a guaranteed boost by investing for the long term. Plus, enjoy reduced fees when you invest more.

Tier 1 Tier 2 Tier 3

Php100,000 / Php1,000,000 / Php5,000,000 /

Minimum investment
US$2,000 US$20,000 US$100,000
2% of the average 2% of the average 3% of the average
Guaranteed loyalty bonus account value for the account value for the account value for the
(paid every 10th and 20th year) last 5 years last 5 years last 5 years
5% of the single 3.5% of the single 0% of the single
Premium charge
premium premium premium

In just one product, you can have unparalleled control over your investments to help you make sure that your family continues on living well.

The succeeding pages of this proposal provide more details on the benefits and features of Asset Master. If you have questions, please call me at the
number specified below, or call the AXA Philippines Customer Care Hotline at (02)85815-292.

JUNIA, ABIGAIL GOMEZ

542004
31075
639275892170

Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM

10 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

Product Highlights
Asset Master is a single-pay variable life insurance product where the premium, net of the company’s charges, is invested into your choice of
funds. The minimum Death Benefit on day 1 is USD 3,125.00. The minimum Death Benefit for any policy year is equal to 125% of Single
Premium less 125% of each partial withdrawal, if any, subject to the limitations provided in Note 17 of this proposal. Only the minimum Death
Benefit is guaranteed. The rest of the benefits, namely the partial and full withdrawal values and the actual Death Benefit at time of death, all
depend on the investment experience of the separate fund/s under your Policy. The Death Benefit is the higher amount between the Account
Value and minimum Death Benefit.
Basic Plan Cover up to Age Sum Insured (USD) Premium (USD)

Asset Master 100 3,125.00 2,500.00

MAIN ASSET
FUND MANAGER/
FUND NAME/FUND OBJECTIVE UNDERLYING RISK CLASS MANAGEMENT ALLOCATION
CUSTODIAN
ASSET CHARGE
Capital Investment Fund
This Bond Fund seeks to achieve long-term capital Metrobank Trust
appreciation and moderate investment returns through Banking
Bond
Group/Citibank
2.00% 0%
income yields of interest-bearing securities issued by the
Philippine government and well-managed Philippine N.A.
corporations. Low

Premium Bond Fund

This Capital Investment Fund seeks to maintain a high Metrobank Trust
level of liquidity to earn moderate investment returns Banking
Bond
Group/Citibank
2.00% 0%
through income yields of US-dollar denominated interest
-bearing securities issued by the Philippine N.A.
government and top Philippine corporations. Medium

Global Dynamic Allocation Fund - Stable

This Bond Fund invests in different funds and provides
access to a diversified portfolio of global fixed income AXA Philippines/
Bond
Citibank N.A.
1.40%* 0%
securities. This fund seeks to maintain a lower level of
portfolio risk
Low
Global Dynamic Allocation Fund - Multi-
Asset
This Balanced Fund invests in different funds and provides AXA Philippines/
access to a diversified portfolio of global investments Multi-Asset
Citibank N.A.
1.75%* 0%
comprised of fixed income securities and equities. This
fund seeks to maintain a moderate level of portfolio risk Medium

Global Dynamic Allocation Fund - Growth

This Equity Fund invests in different funds and provides
access to a diversified portfolio of global equities. This fund AXA Philippines/
Equity
Citibank N.A.
2.00%* 0%
seeks to maintain a higher level of portfolio risk.

High
Global Advantage Fund
This Equity Fund seeks to achieve medium to long term
growth through capital gains and dividends by investing in
stocks that make up the NASDAQ 100 Index that will AXA Philippines/
Equity
Citibank N.A.
2.00% 100%
provide access to a diverse set of stock representation
across different sectors except the financial sector and to High
provide investment results that corresponds generally to
the price and yield performance of the NASDAQ 100 Index.

Asia Growth Fund

This Equity Fund seeks to achieve medium to long term
growth through capital gains and dividends by investing in AXA Philippines/
Equity
Citibank N.A.
2.00% 0%
large to medium-cap Asian equities that will provide access
to a diverse set of medium to large capitalized
representation across economies. High

European Wealth Fund

This Equity Fund seeks to achieve medium to long term
growth through capital gains and dividends by investing in AXA Philippines/
Equity
Citibank N.A.
2.00% 0%
Eurozone equities that will provide access to a diverse set of
medium to large capitalized representation across
economies High
*The Global Dynamic Allocation Funds incur a fee payable to the Fund Manager. Additionally, the underlying funds charge their own management fee/s. Such fees are
already included in the computation of the Net Asset Value per unit, which is the price at which investors subscribe and redeem units of the fund.

Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM

11 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

Key Risks
The value of the funds (and your policy benefits) may go up or down depending on market conditions. As an investment-linked
insurance product, you should understand that the product is subject to certain risks, such as, but not limited to investment,
credit, currency, interest rate, liquidity, mark-to-market, regulatory and taxation risks which could affect the account
or fund value of the whole policy. For better understanding of the nature of these risks, see Note 15 on page 7.

Fees and Charges

This product is subject to fees and charges such as a one-time Premium Charge of 5%, Asset Management Charge as shown
in the previous page and Cost of Insurance, which starts at a monthly rate of USD 0.02 for each thousand of amount at risk (or
USD 0.02 for the first month) and increases with age but will not be higher than USD83.33 for each thousand of amount at risk, and
Surrender Charges of 8%, 4%, 2% and 2% for the first 4 years. Refer to Note 6 on page 7 for the details of the fees.

Valuation
All funds are valued daily or weekly and may be set from time to time. Prices are published in major newspapers weekly and
updated regularly in our website www.axa.com.ph. You can also visit the customer portal to view fund performance. You may refer
to the table below for the Historical Fund Performance.

Surrender
You may surrender or withdraw (partial or full) from your Policy anytime subject to surrender charges depending on when the
surrender transaction occurs. The surrender charge is equal to the amount withdrawn multiplied by a surrender factor of 8%, 4%,
2% and 2% for the 1st to 4th years, respectively.

It is important that you fully understand the features, benefits and accompanying risks of this product. Should you
need further information, you may contact your Financial Executive or call AXA Philippines Customer Care
Hotline at Tel. No. (02) 85815-292.

Historical Fund Performance (as of January 31, 2020)

Year-to-Date Returns Average Annualized
Annualized Annualized
USD Fund Name Return for Return Returns
(LaunchDate) 31-Dec- 31-Dec- 31-Dec- 31-Dec- 31-Dec- 31-Dec- 31-Dec- 31-Dec- 31-Dec- 31-Dec- the last 3 (since fund 1 Year 3 Year 5 Year
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 years inception) Intervals Intervals Intervals

Premium Bond Fund

11.24% 9.19% 13.64% -7.98% 9.20% 0.98% 0.59% 4.16% -3.65% 12.60% 3.24% 6.20% 7.50% 3.24% 2.08%
(4/24/2003)
Capital Investment Fund
1.83% 0.33% 0.91% -1.29% -0.09% -1.58% 0.51% -0.85% -1.45% 1.18% -0.43% 1.37% 0.07% -0.43% -0.41%
(4/24/2003)
Global Advantage Fund
N/A N/A N/A N/A -1.78% 32.51% 16.60% 5.63% 4.65% 35.26% 14.24% 14.14% 12.29% 14.24% 12.48%
(7/19/2012)
Asia Growth Fund
N/A N/A N/A N/A N/A N/A -6.37% -10.48% 1.26% 13.05% -1.27% -1.12% -12.20% -1.27% -2.11%
(9/1/2014)
European Wealth Fund
N/A N/A N/A N/A N/A N/A -6.58% -7.57% -4.13% 21.33% -6.57% -4.75% -19.31% -6.57% -4.76%
(9/1/2014)
Global Dynamic
Allocation Fund - Stable N/A N/A N/A N/A N/A N/A N/A N/A N/A 8.38% N/A N/A N/A N/A N/A
(6/7/2018)
Global Dynamic
Allocation Fund - Multi-
N/A N/A N/A N/A N/A N/A N/A N/A N/A 15.82% N/A N/A N/A N/A N/A
Asset
(6/7/2018)
Global Dynamic
Allocation Fund - Growth N/A N/A N/A N/A N/A N/A N/A N/A N/A 20.48% N/A N/A N/A N/A N/A
(6/7/2018)

Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM

12 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

1. The Fund figures reflected above are not indicative of future performance. You should be aware that the price of units per share and the potential
income from them may go up or down depending on market conditions and thus, are not guaranteed.
2. Average Annualized Performance for 1 Year, 3 Year and 5 Year intervals shown in the tables above represent the indicated Fund’s Average
Annualized Performance using ANY 1 Year Interval, 3 Year Interval and 5 Year Interval, respectively since inception of the funds.
3. The figures are exclusive of charges which will vary depending on the AXA Product where this fund will be used.
4. Please refer to the individual Fund Fact Sheets available at www.axa.com.ph for more information.
5. Fund prices are published every Tuesday in the Business Section of the Philippine Star. Fund prices are also updated daily in our website
www.axa.com.ph. You can also visit the customer portal to view fund performance.

Certified true and correct:

Ronaldo C. San Jose

Chief Financial Officer

Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM

13 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

Illustration of Benefits
End of Annual Charges 3.00% Rate of Return 7.75% Rate of Return 8.00% Rate of Return
Total Single
Policy (Based on 3.00%
Basic Premium Living Benefit Death Benefit Living Benefit Death Benefit Living Benefit Death Benefit
Year Rate of Return)
1 2,500 125 2,446 3,125 2,559 3,125 2,565 3,125
2 2,500 0 2,519 3,125 2,757 3,125 2,770 3,125
3 2,500 0 2,595 3,125 2,971 3,125 2,991 3,125
4 2,500 0 2,672 3,125 3,201 3,201 3,231 3,231
5 2,500 0 2,752 3,125 3,449 3,449 3,489 3,489
10 2,500 0 3,250 3,250 5,093 5,093 5,212 5,212
15 2,500 0 3,768 3,768 7,397 7,397 7,658 7,658
20 2,500 0 4,449 4,449 10,924 10,924 11,440 11,440
25 2,500 0 5,158 5,158 15,866 15,866 16,809 16,809
30 2,500 0 5,979 5,979 23,043 23,043 24,698 24,698
35 2,500 0 6,931 6,931 33,468 33,468 36,289 36,289
40 2,500 0 8,035 8,035 48,609 48,609 53,321 53,321
45 2,500 0 9,315 9,315 70,599 70,599 78,346 78,346
50 2,500 0 10,799 10,799 102,538 102,538 115,116 115,116
55 2,500 0 12,519 12,519 148,927 148,927 169,144 169,144
60 2,500 0 14,513 14,513 216,301 216,301 248,528 248,528
65 2,500 0 16,824 16,824 314,156 314,156 365,169 365,169
70 2,500 0 19,504 19,504 456,280 456,280 536,553 536,553
The rates of return shown above, which are approved by the Insurance Commission, are for illustration purposes only and are
not based on past performance, nor they guarantee future performance. These return figures do not represent expected
returns. The actual return may differ. You may refer to the Historical Fund Performance to check the past performance of AXA
Funds.

*The mid scenario for the Global Dynamic Allocation Funds are based on a 6% rate of return.

Notes
1. This illustration shall form part of the insurance contract once the Policy is issued.
2. These funds and corresponding illustrations are only valid in connection with AXA products solely distributed within the Philippines.
3. All payments and benefits shown are in US Dollars. Payments are acceptable in US Dollars only.
4. The values in the illustration of benefits table are based on the projected performance of your chosen fund/s. Since the fund performance may
vary, the values of your units are not guaranteed and will depend on the actual investment performance at that given period. The projected
returns, which are approved by the Insurance Commission, on investments are based on assumed annual rates of 4%, current interest rates
reflect the historical experience of the chosen fund/s in the past three years, and 10%. These rates are for illustration purposes only and do not
represent maximum or minimum return on your fund.
5. The figures for the Living Benefits include premium deductions for the attached Supplement/s in this proposal.
6. The illustrated values are NET of:
a. One-time Premium Charge of 5% of the single premium;
b. Cost of Insurance (COI) that is deducted monthly by the company to cover the cost of insuring customers. The COI will depend on
two factors that may be re-adjusted from time to time:
(i.) the amount-at-risk or the difference between the death benefit and the account value; and
(ii.)an individual’s risk rate or level of risk depending on multiple factors such as age, gender, and health, among others. COI
starts at a monthly rate of USD 0.02 for each thousand of amount-at-risk and is multiplied to an individual’s risk rate. Your
COI for the first month is USD 0.02 and will increase with age, but it will not be higher than USD83.33 for each thousand
amount-at-risk.
c. An additional Rider Premium shall be deducted from the account value of the policy if applicable.
d. Asset Management Charge depending on the chosen fund/s, as shown in the Product Highlights page above, plus VAT for the chosen
fund/s.
7. The illustrated benefits assume that no withdrawals are made and the current scale of charges remains unchanged.
8. The illustrated values are still subject to a Surrender Charge for withdrawals (partial or full) up to the 4th policy year. The Surrender Charge is
equal to the amount withdrawn multiplied by a surrender factor of 8% / 4% / 2% / 2% for the 1st to 4th years, respectively. Your policy may also
terminate in the event that the available fund values are no longer sufficient to cover for the applicable policy charges. In this case, you may
reinstate your policy within 3 years for as long as the policy’s fund value has not been fully withdrawn, the reinstatement documents have been
submitted, and the necessary charges fully paid.
9. A guaranteed Loyalty Bonus, credited on the 10th and 20th policy years is included in the illustration. The bonus is estimated to be 2% of the
average of the month-end Account Values over the last 60 months.
10. The proposed policy charges used in the illustration summary for proposals on a Guaranteed Issue Basis are based on the standard risk class
without taking into account your own circumstances (e.g. occupation).
11. The company reserves the right to adjust any charges in the plan subject to prior approval of the Insurance Commission.
12. Any withdrawals from the Living Benefit will correspondingly reduce the Death Benefit payable.
13. The investment gains/risks associated with this product are solely to your account.
14. If after purchasing this plan, you realize that it does not fit your financial needs, you may return the policy to AXA
Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM
14 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

14. If after purchasing this plan, you realize that it does not fit your financial needs, you may return the policy to AXA
Philippines within 15 days from the time you receive your policy. AXA Philippines will return to you the Living Benefit and
all initial charges.
15. Top-ups are not allowed under this product.
16. Investment in the funds does not provide guaranteed returns even if invested in Government Securities and High-Grade Prime Investment
Outlets. Your principal and earnings from investment in the fund can be lost in whole or in part when the NAVPU at the time of redemption is
lower than the NAVPU at the time of contribution. Gains from investment is realized when the NAVPU at the time of redemption is higher than
the NAVPU at the time of contribution.
a. Market/Price Risk - The risk of a decline in the value of a security or a portfolio. There is a possibility that an investor will experience
losses due to changes in market prices of securities.
b. Interest Rate Risk - The risk that an investment's value will change due to a change in the absolute level of interest rates, in the
spread between two rates, in the shape of the yield curve or in any other interest rate relationship. There is a possibility that an investor
will experience losses due to changes in interest rates.
c. Credit Risk/Default Risk - The risk of loss of principal or loss of a financial reward stemming from a borrower’s failure to repay a
loan or otherwise meet a contractual obligation. This inability of the borrower to make good on its financial obligations may have
resulted from adverse changes in its financial condition, thus, lowering credit quality of the security, and consequently lowering the
price (market/price risk) which contributes to the difficulty in selling such security. It also includes risk of a counterparty (a party the
Fund Manager trades with) defaulting on a contract to deliver its obligation either in cash or securities.
d. Liquidity Risk - The risk stemming from the lack of marketability of an investment that cannot be bought or sold (convert back to
cash) quickly enough to prevent or minimize a loss.
e. Foreign Exchange Risk - The risk of an investment's value changing due to changes in currency exchange rates.
f. Reinvestment Risk - The risk associated with the possibility of having lower returns or earnings when maturing funds or the interest
earnings of funds are reinvested.
g. Country Risk - A collection of risks associated with investing in a foreign country. These risks include political risk, exchange rate risk,
economic risk, sovereign risk and transfer risk, which refer to the risks of capital being locked up or frozen by government action.
Country risk varies from one country to the next. Some countries have high enough risk to discourage much foreign investment.
h. Mis-selling Risk - The risk that a salesperson misrepresents or misleads an investor about the characteristics of a product or service.
i. Other Risks - other potential risks not enumerated that might affect trade transactions and value of the fund.
17. This proposal was generated on a Guaranteed Issue Basis notwithstanding the state of health of the Insured. A Policy issued on a Guaranteed
Issue Basis is subject to the following conditions:
a. If the Insured’s death occurs during the first two (2) years from the Effective Date of the Policy, the Death Benefit payable shall be as
follows:
i. If the Insured’s death is caused by a Covered Injury, the Death Benefit as defined in the Policy shall be payable
ii.If the Insured’s death is due to causes other than a Covered Injury, AXA Philippines shall pay the Account Value, Premium
Charge and Insurance Charge, notwithstanding any provisions of the Policy to the contrary.
b. If the Insured’s death occurs after two years from the Effective Date of the Policy, the Death Benefit as defined in the Policy shall be
payable.
18. The Rider Premium, if applicable, will be deducted from the Account Value.

A “Covered Injury” is defined as a bodily injury suffered by the Insured which (a) is sustained while the Policy is inforce, (b) is caused, directly and
independently of all other causes, by external, violent and accidental means, and (c) produces visible contusion or wound on the exterior part of the
body (except in the case of drowning or of internal injury revealed by an autopsy).

Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM

15 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

DECLARATION AND ACKNOWLEDGMENTS

A. Investment Risk Profile and Portfolio Risk Acknowledgment
I prefer a high growth investment portfolio and the descriptions below match the risk profile of my intended investment portfolio. I also
acknowledge that the recommended fund allocation ranges resulting from my investment portfolio risk profile is only intended as reference to help
me assess my investment portfolio’s risk appetite and investment objectives.
High Growth Investment Portfolio: A high growth investment portfolio is geared towards higher potential capital growth but subject to higher
level of variability in returns.
• You understand that investing allows for significantly higher returns than savings, but there is a risk that your investments might yield negative
returns and the value of your investments can even be lower than the amount you invested.
• You understand that diversifying your investments over different equity funds and bond funds reduces the volatility of the average annual
returns on your investments.
• You understand that a market can be volatile and that a longer holding period in general reduces the risk of negative average annual returns.
• You want to maximize annual returns on your investments even if this means that there is also a chance of incurring higher negative losses in
any given year.

B. Acknowledgement of Risk Portfolio Re-Classification (For Clients Investing in Products with

Different Risks)
I acknowledge that though I am aware of the results of my investment portfolio risk profile assessment, I have decided to invest instead in
another investment fund or a combination of investment funds which falls outside of the recommended fund allocation ranges indicated by my
investment portfolio risk profile.

C. Investment Policy Statement

I acknowledge that my fund allocation represents the Investment Policy of my portfolio. I have carefully read and understood the investment
objective(s) of my selected fund(s) as well as the risk(s) that it(they) bear(s).

D. Acknowledgement of Variability of Variable Life Insurance Plan

I acknowledge that I have applied with AXA Philippines for a Variable Life Policy, and have reviewed the illustration(s) that shows how a variable life
insurance policy performs using AXA Philippines’ assumptions and based on Insurance Commission’s guidelines on interest rates.

I understand that since the fund performance may vary, the values of my units are not guaranteed and will depend on the actual performance at that
given period and that the value of my Policy could be less than the capital invested. The unit values of my Variable Life Insurance are periodically
published.

I understand that the investment risks under the Policy are to be borne solely by me, as the policyholder.

E. Product Transparency Declaration

I acknowledge that the product has been discussed with and thoroughly explained to me. I understand that:
· I am buying a Variable Life Policy;
· I understand that the proposal was generated on a Guaranteed Issue Basis and the conditions applicable to policies issued on a Guaranteed
Issue Basis has been thoroughly discussed with me.
· The principal and earnings are not guaranteed and the unit price may go up or down depending on the performance of the separate funds;
· The funds will be invested in Equities and/or Bonds or a combination thereof, and will be subject to changes in market conditions;
· The available funds and the risks that they bear have been thoroughly discussed with me, and I have made my Fund Allocation decision based on
my own judgment of and tolerance for these risks; and
· This product is appropriate for a long-term investment horizon.

F. Data Privacy
Any of my/our personal information collected or held by AXA Philippines (whether contained in the application/s or otherwise), may be used in
connection with matching for whatever purpose with such other personal information and/or may be used, stored, disclosed, transferred (whether
within or outside the Philippines) to such persons as AXA Philippines may consider necessary, including without limitation but not limited to any of
its affiliated or related companies, or any individuals/organizations/corporations/entities associated with AXA Philippines:
a. to process and deal with my application/policy;
b. to provide all services related to my application/policy, to promote other products/services by AXA Philippines and its affiliated or
related companies/entities, and to process my information for product development and for marketing purposes;
c. to communicate with me for any purpose and/or to comply with the laws of any applicable jurisdiction.

Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM

16 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Asset Master
LUCY MAE SANTIAGO BAUTISTA, 22, Female

I/We understand that AXA shall use my/our personal information to evaluate and assess my/our application and need for life insurance and
investments, to service any of my/our policies and needs including the evaluation of any future claims and for communication of their marketing
and/or commercial campaigns. I/We also authorize AXA to disclose to any person or entities providing services on AXA’s behalf consistent with the
purpose for which the information was obtained.

These declarations and acknowledgments are made with the

CONFORME: knowledge of the AXA representative whose signature appears below:

Applicant/Policy Owner Date

Signature over Printed Name Financial Advisor/Financial Executive Date
Signature over Printed Name

TO BE FILLED UP BY AXA PHILIPPINES

These declarations and acknowledgements are valid for
the following policy/policies with policy number/s:

Disclosure of Conflict of Interest

The Company adopts a Conflict of Interest Policy and undertakes to disclose any material information which gives rise to actual or potential conflict of
interest to our customers. Company likewise takes all reasonable steps to ensure fair dealings with our customers.

General Disclaimer
All information and opinions provided are of a general nature and for information purposes only. The information and any opinions herein are based
upon sources believed to be reliable. AXA Philippines, its officers and directors make no representations or warranty, expressed or implied, with
respect to the correctness, completeness of the information and opinions in this document. Investment or participation in the Fund(s) is subject to risk
and possible loss of principal. Please carefully read the policy and endorsements and consider the investment objectives, risks, charges and expenses
before investing. You should seek professional advice from your financial, tax, accounting or legal consultant before making an investment. Past
performance is not indicative of future performance.

THIS FINANCIAL PRODUCT OF AXA PHILIPPINES IS NOT INSURED BY THE PHILIPPINE

DEPOSIT INSURANCE CORPORATION (PDIC) AND IS NOT GUARANTEED BY METROBANK
NOR PSBANK.

Created on: 10/05/2020 Date Printed: 10/5/2020 01:41:05 PM

17 of 19 Expiry Date: 12/04/2020 Policy No: 5113336738 Version Number: 6.0.3
Date for Next Insurance Age: 03/07/2021 Plan Code: SPG1 / Rider Code: N/A
 Reference Number: 31075-202010051128-3-02

FINANCIAL UNDERSTANDING SUMMARY

Dear LUCY MAE,

Thank you for providing us with relevant information with regards to your financial
needs.

Based on your current financial situation, which includes, among others, your personal
monthly gross income of 37,500.00, and after taking into consideration your
objectives, risk profile and priorities, you have selected Asset Master GIO for your
Wealth Management need.

The details of your insurance coverage and your insurance premium are summarized in
your Asset Master GIO sales illustration.

JUNIA, ABIGAIL GOMEZ

542004
31075
639275892170

This document is not intended to be a part of the sales illustration of your application form. This is a
summary of the financial needs that you have provided during assessment by your distributor.
 Reference Number: 5113336738

Client's Declaration Form

I have actually read and understood the full text of the Declarations, Agreements and Acknowledgment
of the Forms before signing them:

Application Form: 5113336738

Proposal/Illustration of Benefits: 5113336738

I also understand that this Client’s Declaration Form shall form part of the insurance contract once the
Policy is issued.

LUCY MAE BAUTISTA

Name and Signature of Proposed Insured

Signed in the Philippines

Date of Signing:

IMPORTANT NOTICE:
Application for any life or health insurance must be solicited and signed in the Philippines. Application
signed in Philippine Embassy or Consulate is not allowed. Guidelines on AXA Cross -border policy
apply.