AXA.

Philippines
34th Floor GT Tower International,
6813 Ayala Ave. corner H.V. Dela Costa
St.

redefining/ standards Makati City, Philippines 1227

TIN 000 – 485 226

I NDIVIDUAL APPLICATION FOR GROUP CREDIT UFE INSURANCE

NAME (Last, First, M.I.) SEX: CIVIL STATUS: .

DATE OF BIRTH: PLACE OF BIRTH: NATIONALITY: HEIGHT: WEIGHT: .

• The Policy-Creditor shall be the sole and Irrevocable beneficiary of each Insured- Debtor insured hereunder to t he extent of the unpaid
OCCUPATION: . RANK/LEVEL: .
loan balance of the Insured-Debtor's obligation with the Policyholder-Creditor at the time of the Insured-debtor's death. The amount in excess
of the unpaid
HOMEloan balance· of the Insured-Debtor's obligation with the Policyholder -Creditor at the time of the Insured-Debtor's
ADDRESS: TEL.NO.: death, if any,
.
shall be OFFICE
paid toADDRESS:
the Insured-Debtor's designated revocable beneficiary. TEL.NO.: .

1. Has your application for life insurance ever been declined,

BENEFICIARIES postponed,
DATE OF BIRTH rated, or in any way modified? ( ) Yes
RELATIONSHIP ( ) No
a. Please provide details below for “YES” answer.
b. NAME OF INSURANCE COMPANY: DATE OF APPLICATION:
c. REASON:

2. Have you been treated or been told to have had any neurological, respiratory/lung, heart, abdominal, reproductive or urinary illness,
diabetes, hypertension, tumor, mass, AIDS/HIV related condition, paralysis, or have undergone any
organ transplant or dialysis? ( ) Yes ( ) No

3. Have you been hospitalized as an in-patient or had consultation for any illness or serious injury at any
time during the last 12 months? ( ) Yes ( ) No
4. Please provide details below for "Yes" answer to Question Nos.2 and 3.
a. NAME OF ILLNESS: ATTENDING PHYSICIAN:
b. DATE OF CONSULTATIVE/CONFINEMENT: CLINIC/HOSTPITAL:
( ) Yes ( ) No
5. FOR FEMALE APPLICANTS ONLY; a.) Are you pregnant? if YES, how many months?
 By filling out this form, providing my personal information, and affixing my signature herein I give my full and unconditional consent and waive my
rights under the Republic Act 10173 also known as the " Data Pri vacy Act of 2012" and other relevant laws.

Unless prohibited by law, I hereby authorize any physician, hospital, clinic, insurance company or other organization, institution or person that has
any records or knowledge of my health to disclose to AXA Philippines or its representative any and all information with reference to my health and
medical history or hospitalization, medical advice, treatment. disease, and ailment. A photocopy of this authorization shall be effective and valid as
original.

I declare that the above answers are true and correct to the best of my knowledge and that I have not withheld any relevant information which
might have otherwise affected the acceptance of my proposal. I understand and agree that the Insurance applied for will become effective only upon
acceptance by the Company and the initial premium being fully paid by me.

,,
Any material falsity or misrepresentation in the foregoing shall entitle AXA Philippines to declare the insurance null and void from the beginning, while

_
the same has not been in force for more than one (1) year from the effecti v e d a te , during the life of the Insured.

Signed at on day of

Witness Signature of Proposed Insured

Representative of Creditor

FOR CREDITOR’S USE ONLY FOR AXA Philippines USE ONLY

Group Acct Name/Branch : REMARKS :
Amount of Insurance : Class Rating :
Term of Insurance : Sub – Std. Amt. :
Premium : Others :