Group Life - Individual

The Manufacturers Life Insurance Co. (Phils.), Inc.

Head Office: NEX Tower, 6786 Ayala Avenue, Makati City, 1229, Philippines
Customer Care: +632 8884 7000

Statement of Insurability
Domestic Toll-Free: 1 800 1 888 6268
Website: www.manulife.com.ph
Email: phcustomercare@manulife.com

Please answer completely and accurately and in CAPITAL letters. Answer all fields, put “N/A” if not applicable. Use black ink. Do not use friction
pens. Any change should be counter-signed by the Proposed Insured. In this form, "you" and “your” means the Proposed Insured. "We", “us”,
“our” and “the Company” means the Manufacturers Life Insurance Co. (Phils.), Inc.

Policy No. Name of Policyholder (Entity)

Proposed Insured’s Information

1. Proposed Insured’s Full Name (Last Name, First Name) (Middle Name) Do not know / not applicable 2. Sex Male 3. Civil Single Married
Female Status Other:
4. Date of Birth (mm/dd/yyyy) 5. Country of Birth Philippines Other: 6. City of Birth

7. Nationality Filipino Other: 8. Citizenship/s (indicate all) 9. If Foreign National ACR# or Passport with SIRV/SRRV
Filipino Other: Expiry Date
(mm/dd/yyyy):
10. For Philippine Nationals (please provide both) 11. I am a Citizen, Permanent Resident (Green
Phil ID or SSS or GSIS and Tax Identification Number Card holder) or a Resident of the United
States Agree Disagree
12. Occupation 13. Sources of Funds Salary Business Savings 14. Nature of Business
Remittances (country): __________________________ Other: ____________________
15. Mobile Number 16. Email Address 17. Height cm Weight kgs
+63 ft/in lbs
18. Permanent Residence Address
__________________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________________________________
Floor/No., Building/Street, Subdivision/Village Barangay/District, Town/City Province/State, Country, Zip Code

For Credit Life Insurance

The Proposed Insured is: Type of Loan: Housing Business Personal Loan Amount: Loan Term:
Principal Borrower Salary Real Estate
Co-Borrower Other: _________________________________________________

Beneficiary Information
Address Contact Number Relationship Citizenship/ Place/
Name (Last Name, First Name) (No., Street, Village, Date of Birth Sex Irrevocable?
Mobile: (Country to Proposed Nationality Country
City/Municipality, Province/ (mm/dd/yyyy) (M / F) Yes No
(Middle Name) Do not know / not applicable Code + Mobile No.) Insured (PI) (indicate all) of Birth
State, Country, Zip Code)

Note: Beneficiary is revocable unless specified.

Form No. MP GRP IAGLISI (v. 10/2020) Page 1 of 3

 Address Contact Number Relationship Citizenship/ Place/
Name (Last Name, First Name) (No., Street, Village, Date of Birth Sex Irrevocable?
Mobile: (Country to Proposed Nationality Country
City/Municipality, Province/ (mm/dd/yyyy) (M / F) Yes No
(Middle Name) Do not know / not applicable Code + Mobile No.) Insured (PI) (indicate all) of Birth
State, Country, Zip Code)

Note: Beneficiary is revocable unless specified.

Life Insurance Questions Yes No

19. Have you had any weight change within the last twelve months? If yes please specify: Gain Loss ________ lbs kgs

20. Have you smoked cigarettes within the last twelve months? If yes please specify: ______ sticks per day

21. Have you ever applied for or received benefits, compensation or pension because of sickness or injury?

22. Have you been absent from work because of sickness or injury during the last six months?

23. Have you participated or do you intend to participate in aviation (in any capacity other than as a passenger), racing, scuba diving, or other
hazardous sports? If yes please specify: Activity: _____________________________________________ Frequency of participation in a year: _________

24. Have you had any condition for which medical consultation or treatment is contemplated or has been advised?

25. Have you ever had an application for life or health insurance declined, postponed or modified in any way?

26. Have any of your natural parents or siblings had Dementia (including Alzheimer's disease), Cancer, Cardiomyopathy,
Diabetes, Heart disease, Stroke, Huntington's disease, Parkinson's disease, Polycystic Kidney disease, Familial
Adenomatous Polyposis, Motor Neurone disease, Multiple Sclerosis or Muscular Dystrophy?
If yes, please indicate family member, condition/illness, age at onset, and age at death (if applicable):
______________________________________________________________________________________________________________________________________

27. Have you ever consulted a physician, ever been treated for, or had any known indication of:
a.
Chest pain or heart disorder? Yes No h.
Small or large bowel disorder? Yes No
b.
High blood pressure or stroke? Yes No i.
Stomach or liver disorder? Yes No
c.
Cancer or tumors? Yes No j.
Disorder of the kidney, urine or genital organs? Yes No
d.
Diabetes, gout or thyroid disorder? Yes No k.
Arthritis or rheumatism? Yes No
e.
Epilepsy, nervous or mental disorder? Yes No l.
Back disorder? Yes No
f.
Alcoholism or drug addiction? Yes No m.
Limb disorder? Yes No
g.
Asthma or other lung disorder? Yes No n.
Any other physical impairments, deformities, or Yes No
illness not in this list?

If the answer to any of the Life Insurance Questions is “yes”, please provide details below. Use additional sheets if necessary.

No. Details or Name of Treatment Results Names and Addresses of

Date and Duration (recovery of remaining effects)
Condition Doctors and Hospitals

Form No. MP GRP IAGLISI (v. 10/2020) Page 2 of 3

 Declaration and Agreement
I confirm that my answers in this form and any extra forms attached are
complete and true. I also understand and agree to the following:
1. I agree to be covered under the Group Insurance Policy issued by the
Company.
2. I agree that the insurance issued on this application is subject to the
provisions of the Group Insurance Policy issued by the Company,
which reserves the right to reject the application or rescind the
insurance if there should be a failure on my part, to disclose material
information pertinent to this application.
3. For the information I gave:
• I am allowing the Company to keep them in line with
their records retention policy;
• I will inform the Company of any changes in them as soon as
possible; and
• I will not hold the Company responsible for any claims, loss, liability
and cost as a result of using them for valid purposes.
4. The Company can correct this application to fix obvious mistakes
and missing information.
5. I authorize the Company, its reinsurer and/or its duly authorized
representatives to request and secure all information or documents
on my health which are available from any medical practitioner,
government or private hospital/clinic, medical offices or clinics in
relation to my application for insurance and/or insurance action
and/or claims that may arise from it. I agree that a photographic copy
of this authorization shall be valid as the original. This also
discharges any such physician, medical practitioner, hospital, clinic,
medical office or facility and all members of its staff from any
liability or obligation by reason of the release of the
information/document/records.
6. Disclosure:
In accordance with the Insurance Commission's Circular Letter No.
2016-54, as may be amended from time to time, your (Insured)
medical information will be uploaded to a Medical Information
Database accessible to life insurance companies for the purpose of
enhancing risk assessment and preventing fraud. Once uploaded, all
life insurance companies will only have limited access to your
information in order to protect your right to privacy in accordance
with law. A copy of Circular Letter No. 2016-54 may be accessed at
the Insurance Commission’s website at www.insurance.gov.ph.
7. The Company collects and uses my personal and sensitive information
to operate an insurance business. By signing this form and continuing
to avail of the Company’s products and services, I agree that the
information I provided (including the information of third parties) and
any subsequent changes to it can be processed, shared, disclosed,
transferred or used by the Company, including its shareholders,
directors and employees, affiliates, subsidiaries, business partners,
any member of the Manulife Financial Group (including those located
________________________________________________________________ ____________________________________________
Proposed Insured Signature over Printed Name Place Signed
Form No. MP GRP IAGLISI (v. 10/2020)
overseas), advisors, representatives, industry associations and
databases, local and foreign authorities having jurisdiction over
companies within the Manulife Financial Group, external
auditors/counsels, and its third party service providers (whether
within or outside the Philippines) within the rules set by the Data
Privacy Act of 2012, as may be amended from time to time,
relevant regulations and the Company’s privacy policy available at
www.manulife.com.ph/Customer-Privacy-Policy for purposes of:
• underwriting and approving my application;
• administering, serving and reinsuring my policy;
• marketing of products and services offered by the Company, any
member of the Manulife Financial Group and those of its business
partners; promoting, getting feedback on its products and services,
and measuring client satisfaction;
• conducting data analytics and doing automated data processing;
• preventing money laundering or terrorist financing activities;
• complying with reportorial and regulatory requirements of both
local and foreign regulatory authorities (including local and
foreign tax authorities and stock exchanges) as well as other
legal, regulatory or contractual obligations of any member within
the Manulife Financial Group, relating to information sharing, tax
reporting or otherwise;
• the Company’s internal purposes such as governance, risk,
actuarial, claims and underwriting management, and reporting; and
• for other reasonable purposes related to the services provided.
8. During the effectivity of the contract/policy, I agree to the following:
in case the Company is unable to comply with relevant customer due
diligence (CDD) measures, as required under the Anti-Money
Laundering Act, as amended and relevant issuances, due to my fault,
the Company may apply the following: (a) measures to restrict the
services available or prohibit any further transactions on the
contract/policy until full and proper CDD measures have been
successfully conducted; and (b) in case the foregoing is
unsuccessful, terminate business relationship, which shall only
entitle me to receive the unused portions of premium or withdrawal
value, if any, whichever is applicable. I also agree to be bound by
obligations set out in relevant United Nations Security Council
Resolutions relating to the prevention and suppression of
proliferation financing of weapons of mass destruction, including the
freezing and unfreezing actions as well as prohibitions from
conducting transactions with designated persons and entities.
9. I will not unreasonably cancel the consent, authorization and other
declarations given herein which could result to the Company or any
member of the Manulife Financial Group violating any law, rules,
regulations or guidelines or its obligation under any contract or
commitment with local or foreign regulators, governmental bodies or
industry recognized bodies (whether within or outside the Philippines).
______________________________
Date Signed (mm/dd/yyyy)
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