Policy Number

600 - 0066305

Application Number H 53248-202301280313-2-04

Application Form for Global Health Access

An insurance contract is a contract of utmost good faith and the Proposed Principal
Insured/Proposed Owner and Dependent(s) is required to disclose ALL material facts FOR OFFICE USE ONLY
to AXA Philippines (“us”). Otherwise, the insurance policy may not be valid. All
answers to the questions stipulated in this Application Form are the basis of and are Date Received:
an inseparable part of the insurance policy. In case of doubt as to whether a fact is Time Received:
material or not, the fact should be disclosed. Receiving
Dept./Office:

1. DETAILS OF THE PROPOSED PRINCIPAL INSURED/PROPOSED OWNER

Full Name MIRA WILFREDO SIBALA

Date of Birth 01/19/1956
Place of Birth Tanjay Negros Occidental
Sex MALE
Height 5' 4''
Weight 160 lbs
Nationality Philippines
Civil Status Married
Principal Country of Residence
This refers to the country where the Proposed Principal Insured lives or intends to stay for
most of the year being one hundred eighty five (185) days or more and which will be Philippines
shown as the Proposed Principal Insured’s address and place of residence in our records.

Is the Proposed Principal Insured a US citizen or a US tax resident? If yes, then NO

please provide US TIN or SSN.

Identity Number (TIN, SSS or GSIS) Drivers License: D19-91-045263

RESIDENCE/PRESENT ADDRESS 45 2nd Street Villa Gloria BARANGAY SAN ISIDRO ANGONO RIZAL 1930

PERMANENT ADDRESS
(IF DIFFERENT FROM RESIDENCE ADDRESS) 45 2nd Street Villa Gloria BARANGAY SAN ISIDRO ANGONO RIZAL 1930

BUSINESS ADDRESS 45 2nd Street Villa Gloria BARANGAY SAN ISIDRO ANGONO RIZAL 1930

SOURCE OF FUNDS Salary:101,340.00;

NATURE OF BUSINESS/WORK Occupation: Businessman; Nature of Business: Menchandize; Employer: Wilmans

(Please indicate source of fund; if employed, please include name of employer and position) Thirst;

PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business

Home:
Contact Information Office:
Mobile: 630969602088
Email: mirawilmar9@gmail.com
Does the Proposed Principal Insured have a current International Health cover No
with any other insurer? If yes, please provide details in the declaration of
existing international health insurance page.
Are the Family Members to be insured (if any) also covered under the same
International Health cover as the Proposed Principal Insured? If yes, please
No
provide details in the declaration of existing international health insurance
page.
Does the Proposed Principal Insured want to transfer the current International
Health cover to Global Health Access? No

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

Do you have any Beneficial Owner? NO

Definition of beneficial owner per 2018 IRR of RA 9160, otherwise known as the AML Act of 2001, as amended.

“(l) “Beneficial Owner” refers to any natural person who: (1) Ultimately owns or controls the customer and/or on whose behalf a transaction or activity is being
conducted; (2) Has ultimate effective control over a juridical person or legal arrangement; or (3) Owns, at least, twenty percent (20%) shares, contributions or
equity interest in a juridical person or legal arrangement.

Control includes whether the control is exerted by means of trusts, agreements, arrangements, understandings, or practices, and whether or not the individual can
exercise control through making decisions about financial and operating policies.”

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

(Limited to Spouse, Children and those with insurable interest based on Section 10 of the Insurance Code of the
2. FAMILY MEMBERS TO BE INCLUDED IN THE PLAN Philippines.)

Sec. 10. Every person has an insurable interest in the life and health: (c) Of any person under a legal obligation to him for the payment of money, or respecting
(a) Of himself, of his spouse and of his children; property or services, of which death or illness might delay or prevent the performance; and

(b) Of any person on whom he depends wholly or in part for education or support, or in (d) Of any person upon whose life any estate or interest vested in him depends.
whom he has a pecuniary interest;

Principal Country Relationship to Proposed

Full Name Date of Birth Sex Height Weight Nationality Civil Status
of Residence Principal Insured

3. BASIC PLAN DETAILS

Area of Cover Worldwide Excluding US

Plan Selected Gold Lite Plus

Annual Deductible PHP 200,000

Mode of Payment Quarterly

Method of Payment ADA

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

4. OTHER INSURANCE DETAILS

Please answer all the questions in full and to the best of your knowledge. If you are uncertain about whether the additional information you have is
necessary to be declared, please declare anyway. It can only help us determine if our product will cater to your specific requirements.
Proposed Family Family Family Family Family
Principal Insured Member 1 Member 2 Member 3 Member 4 Member 5
Please write down in the space provided the
Full name of Full name of Full name of Full name of Full name of
names of the persons to be insured according WILFREDO MIRA
Family member Family member Family member Family member Family member
to the sequence in the previous pages.

Has the person to be insured

a) ever had a life, health or critical
illness application that was Yes No Yes No Yes No Yes No Yes No Yes No
declined, deferred, or accepted
with higher than standard
premiums or an exclusion applied
on health grounds?
b) presently receiving a disability
benefit or incapable for work or
Yes No Yes No Yes No Yes No Yes No Yes No
have ever made an insurance claim
for disability, accident, medical care
or critical illness and/or other
insurance benefits?

If you answered “Yes” in the Other Insurance Details section, please provide details of “Yes” responses in the table below.

Question Details
Person to be insured Name of Insurer (date of occurrence/claim, terms offered and reason,
No.
claim amount, benefit type/source/reason for claim)

5. UNDERWRITING QUESTIONS (To be completed for all persons to be insured)

Disclosure: In accordance with the Insurance Commision’s Circular Letter No. 2016-54, your 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.

Please answer all the questions in full and to the best of your knowledge. If you are uncertain about whether the additional information you have is
necessary to be declared, please declare anyway. It can only help us determine if our product will cater to your specific requirements.

Proposed Family Family Family Family Family

Principal Insured Member 1 Member 2 Member 3 Member 4 Member 5
Please write down in the space provided the
names of the persons to be insured Full name of Full name of Full name of Full name of Full name of
WILFREDO MIRA
according to the sequence in the previous Family member Family member Family member Family member Family member
pages.

1. Has the person to be insured ever

been treated for or ever had any sign or
symptom of, or undergone
consultations, investigations, medication,
monitoring or advice for
ANY of the following:

a) Brain or Nervous System

Yes No Yes No Yes No Yes No Yes No Yes No
Disorder/Disease such as
Alzheimer’s Disease, Amyotrophic
Lateral Sclerosis (ALS), Cerebral
Palsy, Dementia, Hydrocephalus,
Multiple Sclerosis, Myasthenia
Gravis, Parkinson’s Disease,
Muscular Dystrophy
b) Mental Health Disorder such as
Psychosis, Schizophrenia, Yes No Yes No Yes No Yes No Yes No Yes No
Depression, Attention Deficit
Disorder (ADD) / Attention Deficit
Hyperactivity Disorder (ADHD)

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

Proposed Family Family Family Family Family

Principal Insured Member 1 Member 2 Member 3 Member 4 Member 5
Please write down in the space provided the
names of the persons to be insured Full name of Full name of Full name of Full name of Full name of
WILFREDO MIRA
according to the sequence in the previous Family member Family member Family member Family member Family member
pages.

c) Blood and Lymphatic System

Yes No Yes No Yes No Yes No Yes No Yes No
Disorder such as
Hodgkin’s Lymphoma, Multiple
Myeloma, Thalassemia,
Antiphospholipid Syndrome (APAS)

d) Cancer of any type, Malignant

Yes No Yes No Yes No Yes No Yes No Yes No
tumor, Leukemia
e) Chronic Respiratory Conditions such
as Chronic Obstructive Pulmonary Yes No Yes No Yes No Yes No Yes No Yes No
Disease, Chronic Asthma, Chronic
Bronchitis, Emphysema

f) Eye, Ear, Nose & Throat Disorder

such as Corneal Ulcer, Deafness, Yes No Yes No Yes No Yes No Yes No Yes No
Glaucoma, Retinal Detachment,
Meniere’s Disease/Syndrome

g) Heart and/or Cerebrovascular

disease such as Angina (Chest pain), Yes No Yes No Yes No Yes No Yes No Yes No
Heart Attack, Abdominal Aortic
Aneurysm (AAA), Atrial Fibrillation
(AF),Cerebrovascular Accident (CVA)
or stroke including Transient
Ischemic Attack(TIA),
Cardiomyopathy, Supraventricular
Tachycardia (SVT), Murmurs, Heart
Failure, Heart Valvular Disease (such
as Valvular Insufficiency/
Regurgitation, Mitral Valve
Prolapse), Abnormal Heart Beat, or
any Heart/Blood/Vascular Diseases.

h) Gastrointestinal Disorder such as

Liver Cirrhosis, Fatty Liver, Colitis Yes No Yes No Yes No Yes No Yes No Yes No
(Ulcerative), Crohn’s Disease,
Hepatitis B, Hepatitis C

i) Kidney and Urinary Tract Disorder

such as Chronic Renal Failure, Yes No Yes No Yes No Yes No Yes No Yes No
Chronic Kidney Disease, Polycystic
Kidney Disease
j) Human Immunodeficiency Virus
Yes No Yes No Yes No Yes No Yes No Yes No
(HIV), Acquired Immunodeficiency
Syndrome (AIDS), AIDS Related
Complex or any other AIDS related
condition
k) Hypertension (High Blood Pressure),
Yes No Yes No Yes No Yes No Yes No Yes No
High Cholesterol, Dyslipidemia
l) Diabetes, other Endocrine Disorders
Impaired Glucose Tolerance, Yes No Yes No Yes No Yes No Yes No Yes No
Impaired Fasting Glucose

m) Musculoskeletal Diseases and

Autoimmune Diseases such as Yes No Yes No Yes No Yes No Yes No Yes No
Systemic Lupus Erythematosus,
Psoriatic Arthritis, Rheumatoid
Arthritis, Dermatomyositis, Mast
Cell Activation Syndrome (MCAS),
Degenerative Joint Disease
n) Congenital Disorders such as Down
Syndrome Yes No Yes No Yes No Yes No Yes No Yes No

o) Transplantations, Prosthetic
implants & appliances in the body Yes No Yes No Yes No Yes No Yes No Yes No
(e.g. shunts, pace-makers, or joint
replacements)

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

Proposed Family Family Family Family Family

Principal Insured Member 1 Member 2 Member 3 Member 4 Member 5
Please write down in the space provided the
names of the persons to be insured Full name of Full name of Full name of Full name of Full name of
WILFREDO MIRA
according to the sequence in the previous Family member Family member Family member Family member Family member
pages.

2. Other than those already disclosed

elsewhere in this form, has the person
to be insured:

a) Ever been prescribed, advised, or Yes No Yes No Yes No Yes No Yes No Yes No
undergone any medication or
medical treatment;
b) Currently taking any medication or
medical treatment whether Yes No Yes No Yes No Yes No Yes No Yes No
prescribed or not?
3. Other than those already disclosed
elsewhere in this form, has the person
to be insured:

a) Ever been hospitalized for more Yes No Yes No Yes No Yes No Yes No Yes No
than five (5) days; or
b) Undergone any surgery or Outpatient
procedures of any kind,
Yes No Yes No Yes No Yes No Yes No Yes No
such as but not limited to, cataract
extraction, excision of mass or
tumor, chemotherapy, incision and
drainage, colonoscopy and other
endoscopic procedures, blood
transfusion, ophthalmologic
procedures, casting, hemodialysis,
dilatation & curettage, radioactive
iodine therapy, etc.
4. Has the person to be insured:

a) Ever had results/investigations that

are abnormal or that fall outside the Yes No Yes No Yes No Yes No Yes No Yes No
reference range, for example but
not limited to biopsy, endoscopy,
pap smear, mammogram, breast
ultrasound, Prostate-Specific Antigen
(PSA) test, prostate examination,
tumor marker, blood tests, cancer
screening tests, health checks, or
pathology;

b) Currently awaiting the completion

Yes No Yes No Yes No Yes No Yes No Yes No
or results of any medical
investigation or diagnostic tests;

c) Intending to seek or currently

Yes No Yes No Yes No Yes No Yes No Yes No
seeking any medical advice,
examination, or procedure other
than Annual Physical Exam or
Executive Check up?

If you answered “Yes” in the Underwriting Questions section, please provide details of “Yes” responses in the table below.

Details of medical condition Name & address of

Question Present state of
Person to be insured (including date of first and last consultation, nature of treatment, dosage,results and each doctor or
No. health
where applicable, state the area of the body affected, e.g. right eye, left leg, etc.) hospital
WILFREDO SIBALA MIRA 1.k. High Blood Healthy Life style ... Angono Medics Ho...

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

6. CLIENT DETAILS

QUESTIONS:
1. Do you smoke cigarettes/e-cigarettes/vape/smokeless tobacco?
(If yes, indicate no. of sticks/packet per day, ml per day & no. of years)

2. Are you and/or your immediate family member entrusted with appointive or elective position in the Philippines or in a foreign state, a senior politician,
judicial or military official, senior executive of government or state-owned or controlled corporations or political party official?

Question 1 Question 2
Proposed Principal Insured No NO
WILFREDO MIRA Position/Public Office:

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

7. TELEPHONE UNDERWRITING AUTHORIZATION

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

Preference: During Office Hours Others Specify ______________________

8. DECLARATIONS AND AGREEMENT BY THE PROPOSED OWNER FOR AND ON BEHALF OF ALL THE PERSONS
TO BE INSURED:

1. I/We hereby apply for Global Health Access insurance policy underwritten by AXA Philippines (“AXA”). By signing this Application Form, I/We confirm that
I/We agree to accept the terms, conditions, exclusions and limitations stated in the Global Health Access policy contract and that I/we confirm that I/we
read this Application Form carefully and the questions were fully explained to me/us in a language/dialect which I/We understand. I/We 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 I/We hereby declare that to the best of my/our knowledge and belief that the statements and answers given in this Application Form are true and complete
and that I/we have not withheld any material facts, that is, facts likely to influence the assessment and acceptance of this Application Form. I/We
understand that any mis-statement of facts, whether by commission or by omission may be grounds for AXA, in its absolute and sole discretion, to decline
to pay any benefit under the policy and also, to void the policy. I/We agree that this Application Form, together with any additional statements signed by
me/us which shall be deemed to be part of this declaration, shall be the basis of the contract of insurance.

3. I/We agree that if the health status of any of the above mentioned persons to be insured changes after this Application Form is signed and before AXA issues
the policy, I/we shall immediately notify AXA of the changes, otherwise, AXA reserves the right to void the policy.

4. I/We understand and agree that AXA has the right to accept or decline this application. If AXA accepts my/our application, I/we agree to let AXA issue the
formal policy documents.

5. I/We understand that AXA reserves the right to request for a copy of the latest medical report from me/us at my/our own expense should further medical
information be required.

6. I/We also agree that in case of any claims, I/we authorize any hospital, physician or other person who has attended to us, or has examined us or who is
authorized to maintain medical records to disclose, when requested to do so by AXA, any and all information with respect to any illness or injury, medical
history or treatment. A photocopy of this authorization shall be considered as effective and valid as the original.

7. 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 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.

8. I/We authorize AXA to request and obtain from third parties, whether government agencies or private entities, any information concerning me/us relevant
to this Application Form, including medical or financial information.

9. 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 also authorize AXA to disclose my/our personal information to affiliated entity(ies), or to persons or entities providing services on AXA’s behalf, or to
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, consistent with the purpose for which the information was obtained. I/We understand
that AXA does not sell any of my/our personal information.

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Application Form for Global Health Access Application Number H 53248-202301280313-2-04

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.

10. During the effectivity of the Policy,

a. In case AXA Philippines 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/our fault, AXA Philippines may apply the following:
i. Measures to restrict the services available or prohibit any further transactions on the Policy until full and proper CDD measures
have been successfully conducted; and
ii. In case the foregoing is unsuccessful, terminate business relationship. The exercise of AXA Philippines of this measure shall only
entitle me/us to receive the unused portions of premium or withdrawal value, if any, whichever is applicable.

b. 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.

11. I/We declare that I/we have informed AXA of all my/our citizenships, residencies and tax residencies, and provided AXA with my/our taxpayer identification
number(s). I/We agree to promptly update AXA of any changes to said information. I/We authorize AXA 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 shall have the right to: (a) require the claimant(s) and/or payee(s) of the policy to provide AXA with their above-mentioned personal
information and/or sign such documents as AXA 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 may provide my/our personal information to such government or taxation authority(ies) to comply with the applicable
laws and regulations.

12. I/We understand that AXA PH will store my/our personal information for at least five (5) years or a period as may be allowed under the Data Privacy Act and
applicable laws and regulations.

13. I/We understand that AXA PH, upon my/our request, will provide the contact details of the personal information controller or the responsible officer in
charge of the custody of my/our personal information.

14. The premiums paid for the insurance 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 may, in its discretion, disclose certain information
about me/us or about my policy.

15. I/We confirm that my/our Principal Country of residence is stated correctly in Part 1 of this Application Form. I/We understand and agree to inform AXA
immediately if any of the member changes the Principal Country of Residence and AXA reserves the right to revise the premium or to decline to continue
the cover.

16. 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 Principal Insured shall automatically become the new Owner of the policy in the event that the
Owner predeceases the Principal Insured person while the policy is in force.

17. I/We also understand that the membership card(s) issued for this policy are to be used only for admissions to hospitals for treatments within the policy
terms and conditions. In the event that charges incurred are not claimable from the policy for any reason, I/we shall undertake to pay AXA within 30 days
from the receipt of all expenses that are not claimable under the policy. I/We further agree to return the membership card(s) upon request from AXA or on
termination of the policy or termination of coverage for any insured person.

18. 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.

19. There shall be no contract of insurance unless and until a policy is issued on this Application Form and the full first premium of the basic health insurance
and any special benefit applied for, according to the mode of payment specified in answer to Part 4, is actually paid during the lifetime and good health of
all persons to be insured.

20. I/We have read and fully understood the Health Insurance Proposal (or the illustration of benefits) for the policy applied for.

21. 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.

NPH1GHAAF-1018 9/21
Application Form for Global Health Access Application Number H 53248-202301280313-2-04

22. I/We authorize AXA Philippines to credit new business payment refund or AXA initiated payments, if any, to my nominated bank account number as may be
indicated on my signed Auto-Debit Arrangement Form (ADA Form).

I understand and agree by filling out my persomal information above, I authorize AXA Philippines, including its affiliates, subsidiaries, third parties contracted
by AXA Philippines, to use said personal information to evaluate and assess my request.

I consent to receive notices and announcements for marketing ourposes via Short Messaging Services (SMS), email, other electronic platform, or telephone
call from AXA Philippines, its affiliates, subsidiaries, including any person or entities providing services on AXA's behalf, consistent with the purpose for
which the information was obtained.

I agree for my agent/financial advisor to have access to my politicy details and claims transactions, and I authorize AXA Philippines to discuss and/or share
claims and medical information to my agent/financial advisor.

NPH1GHAAF-1018 10/21
Application Form for Global Health Access Application Number H 53248-202301280313-2-04

WILFREDO SIBALA MIRA

Signature (Proposed Principal Insured) Signature (Proposed Owner)

Date of Signing: 01/31/2023 Place of Signing: ANGONO RIZAL

**(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 Principal Insured signed this Application Form in my presence.

Name of Advisor/FE: DECOMOTAN, RYAN PAUL B Name of Advisor/FE:

Code: Code:
20780 4 53248

Signature: Signature:

9. DISTRIBUTOR’S DECLARATION

I/We ensure that I/we, as the distributor, have guided the client in completing all relevant and necessary information to assist the Company in assessing the
application. I/We 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/We 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: DECOMOTAN, RYAN PAUL B Name of Advisor/FE:

Signature: Signature:

CONTACT US
For any concerns or queries, you are welcome to contact us on the details below:
Customer Service Hotline: (+632) 85815-AXA (292), Operating Hours: 8:00 AM - 8:00 PM, Monday - Friday
Email: customer.service@axa.com.ph

Alternatively, you can write to:

AXA Philippines - Customer Service Department
34th Floor, GT Tower International
6813 Ayala Ave. corner H.V. Dela Costa St.
Makati City, Philippines 1226

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.

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 Second Level Answers Reference Number: 53248-202301280313-2-04

UNDERWRITING QUESTIONS

Details of medical condition

Name & address of
Question (including date of first and last consultation, nature of treatment, Present state of
Person to be insured dosage,results and where applicable, state the area of the body
each doctor or
No. health
affected, e.g. right eye, left leg, etc.) hospital

WILFREDO SIBALA MIRA 1.k. High Blood Healthy Life style and Angono Medics
controlled High Blood Hospital
 Proposed Principal Insured:
WILFREDO MIRA - Age 67, MALE

Policyowner or Payor:
Wilfredo Mira

Global Health Access

Dear Wilfredo,

Congratulations on taking a vital step to secure your health with AXA, global leader in insurance. AXA Philippines
is the formidable synergy between two financial giants --- the AXA Group and the Metrobank Group.

Our Global Health Solution is designed to provide you world-class extensive medical coverage for inpatient
treatment, along with benefits such as limited outpatient care, emergency care and medical evacuation. This will
ensure that you can access the best healthcare anytime, here and abroad.

We are delighted to share with you the details of your chosen plan, Global Health Access - Gold Lite Plus. Below
is a summary of your plan and the benefits you can enjoy.

HEALTH PLAN SUMMARY

Area of Cover Worldwide excluding US

Annual Plan Limit PHP 100,000,000
Annual Deductible PHP 200,000
Outside Area of Cover Emergency treatment only and up to PHP 10,000,000

Limited Outpatient Care Inpatient Care Emergency Care Value-added Benefits

· Consultations · In-patient hospital · Emergencies · Health at Hand

· Diagnostic scans charges and · International · 2nd Medical Opinion
· Laboratory accommodations Emergency Medical
o Including pre/post Assistance
investigations
· Executive Check-ups outpatient · Road ambulance
treatment transport
· Special Outpatient
conditions
o Dialysis
o Radiotherapy
o Chemotherapy

For a yearly maximum benefit of PHP 100,000,000, your Annual Premium will be PHP 99,029.00 . You can pay
semi-annually for only PHP 51,495.08 or quarterly for only PHP 26,737.83.

The succeeding pages of this proposal provide more details on the benefits and features of Global Health
Access. Benefits may be subject to limits, please refer to your chosen plan’s inclusions/exclusions/limits.

Again, thank you for your interest in Global Health Access. Should you need assistance or clarification, please
call me at the number specified below or call the AXA Customer Care Hotline at Tel. No. +632-8-581-5292.

RYAN PAUL B DECOMOTAN

20780
53248
639615147058

Page 1 of 7 Policy No. 600-0066305 Expiry Date: 03/29/2023

Created Date: 01/28/2023 Printed Date: 01/31/2023 Date of Next Insurance Age: Principal Insured: 07/21/2023
Version Number: 3.10.15
Plan Code: GHX54
 Global Health Access
for: Wilfredo Mira, 67

Premium Breakdown:
The initial Annual premium for the 1st policy year and the estimated Annual premium for the following 2 years are
as follows:

Insured Issue Age Annual Premium Annual Premium Annual Premium

(1st Policy Year) (2nd Policy Year) (3rd Policy Year)
Wilfredo Mira 67 PHP 99,029.00 PHP 106,517.00 PHP 113,381.00

Notes:
1. The first year premium is based on the age nearest birthday of the insureds and hence subject to change
depending on the policy issuance date.
2. Premiums will change according to the attained age on renewal. The premiums shown are those
currently in effect, but the premiums may change upon renewal of the plan and depend on those in
effect at the date of renewal .

COOLING -OFF PERIOD

If you are not completely satisfied with this Policy, you may return it to our Home Office or any of our branch
offices within fifteen (15) days after receipt of the Policy, together with the membership card(s) and a written
notice requesting cancellation. On such cancellation, you will be entitled to a full refund of the initial premium
paid, provided that no claims have been made.

Page 2 of 7 Policy No. 600-0066305 Expiry Date: 03/29/2023

Created Date: 01/28/2023 Printed Date: 01/31/2023 Date of Next Insurance Age: Principal Insured: 07/21/2023
Version Number: 3.10.15
Plan Code: GHX54
 Global Health Access
for: Wilfredo Mira, 67

BENEFITS TABLE
Area of cover Worldwide excluding US

Overall yearly maximum limit up to : PHP 100,000,000

Level of reimbursement Reasonable and customary (R&C) charges
Outside area of cover Emergency treatment only and up to
PHP 10,000,000
In-patient and daycare treatment Pre-approval is required for cashless transaction of the
following benefits:
a) For in-patient treatment or day-care treatment in the
Philippines, it is a single room up to PHP7,500.00 per night.
Daily accommodation charges7
b) For in-patient treatment or day-care treatment outside the
Philippines, it is a standard single room.
Hospital charges7 Included for eligible expenses
Organ Transplant7 Included for eligible expenses
Reconstructive surgery7 Included for eligible expenses
Surgical implants7 Included for eligible expenses
Companion accommodation up to (per night)7 PHP 8,000
Cash benefit, per night6 PHP 10,000
In-patient treatment for AIDS/HIV7 (available after 5
consecutive years of membership on the same plan)
PHP 1,000,000 in an insured person's lifetime
Coverage will apply when signs or symptoms are present for
the first time after five years of continuous coverage under
the plan and any renewal thereof to an all-inclusive limit up
to
In-patient rehabilitation7 Included - up to 28 days4
Included - within 90 days prior to hospital admission and 90
Pre- and post-hospitalization Outpatient treatment7 days immediately following discharge from hospital as an in-
patient
Applicable in-patient direct billing network Global directory of hospitals
Pre-approval is required for cashless transaction of the
Outpatient treatment
following benefits:
Radiotherapy and Chemotherapy7 Included for eligible expenses
Kidney Dialysis Treatment7 Included for eligible expenses
Surgical procedures received as an outpatient Included for eligible expenses
Primary and Specialist Care
Up to PHP 1,000 per visit, maximum of 15 visits per year
Diagnostic scans

Physiotherapy, Occupational Therapy and Speech Therapy5 , 7 Only as part of ‘Pre- and Post-Hospitalization Outpatient Treatment’
Emergency treatment
Emergency Outpatient Treatment due to an accident
Emergency Outpatient Treatment due to non-accident
Other benefits
Hormone Replacement Therapy7
Health screen/Executive Checkup
Note: Benefit is payable only after 50% of the first year
annualized premium is paid. All advance payments shall not
be considered for the purpose of availing this benefit
Benefit
Included for eligible expenses
Share the same limit with primary and specialist care, and
diagnostic scan of Outpatient Treatment.
Pre-approval is required for cashless transaction of the
following benefits:
Only as part of Post-Hospitalization Outpatient Treatment’
Benefit
Up to PHP 20,000
Inner limit for reimbursement of Over-the-Counter (OTC)
vitamins is PHP 2,500 per policy year under Health
Screen/Executive Checkup limit

Premium payments in excess of the current premium due are

considered advance payments.

Page 3 of 7 Policy No. 600-0066305 Expiry Date: 03/29/2023

Created Date: 01/28/2023 Printed Date: 01/31/2023 Date of Next Insurance Age: Principal Insured: 07/21/2023
Version Number: 3.10.15
Plan Code: GHX54
 Global Health Access
for: Wilfredo Mira, 67

Accidental damage to teeth Included for eligible expenses

Oral and maxillofacial surgery7 Included for eligible expenses
Local road ambulance transport7 Included for eligible expenses
International Emergency Medical Assistance Included for eligible expenses
Pre- and post-natal complications7 (available after 12
consecutive months of membership) Included for eligible expenses
New Born Accommodation 7 Included for eligible expenses
Psychiatric treatment up to7 PHP 400,000 (for In-Patient Treatment only)
Hospice and palliative care6 (available after 12 consecutive
months of membership) up to PHP 750,000 in an insured person's lifetime
Second Medical Opinion Included
Health at Hand Included

Notes:
1) The benefit limits are all in Philippine Pesos. Premium and eligible claims will be paid in Philippine Pesos unless a different
claims reimbursement currency is preferred by you or the insured person at the time of claim. If we could process the eligible
claims in your preferred claims reimbursement currency, please note that you or the insured person would have to bear all
bank/credit charges and foreign exchange losses (if applicable).

2) The benefit limits are per insured person each policy year unless otherwise specified and are reduced each time the insured
person claim only by the net amount (less any deductible or co-insurance) we have actually paid. Please refer to the policy
wording on the full terms and conditions applying to these benefits.

3) Pre-approval is required for cashless transaction before receiving any planned in-patient and Outpatient treatment
recommended by a medical practitioner. Policyholder should contact us before the scheduled treatment to obtain our approval.
By seeking pre-approval, we can confirm the following:
· The planned treatment/s is eligible under the policy
· The planned treatment/s is medically necessary
· The planned treatment/s is within reasonable and customary (R&C) cost
· The planned treatment/s cost falls within the remaining benefit limit of the plan

4) We will pay for in-patient rehabilitation when:

· it is carried out by a medical practitioner specializing in rehabilitation; and
· it is carried out in a rehabilitation hospital or unit which is recognized by us; and
· the treatment could not be carried out on an Outpatient basis, and
· the costs have been agreed, in writing by us before the rehabilitation begins.
We will not pay for in-patient rehabilitation for more than twenty-eight (28) days except in cases such as in severe central
nervous system damage caused by external trauma. For cases such as in severe central nervous system damage by external
trauma, we will not pay for in-patient rehabilitation for more than one hundred eighty (180) days.

5) Subject to the limits applicable to the insured person’s plan, we will pay for treatment given by a physiotherapist, occupational
therapist or speech therapist, who is recognized by us and registered to practice where the eligible treatment is given.

Benefit is payable only following in-patient treatment for an eligible medical condition, provided that your insured person has
been covered under the policy since before the in-patient treatment commenced.

Treatment given by physiotherapist, occupational therapist or speech therapist must be under the medical supervision of a
medical practitioner. Medical supervision means that the reason for referral, where applicable, has been initiated by the medical
practitioner who has defined a diagnosis.

There must be a clear treatment plan from the physiotherapist, occupational therapist or speech therapist with an end point and
expected outcome.

6) If the policyholder has opted for annual deductible at the time of application (please refer to the policy specifications), the annual
deductible will apply to all eligible in-patient treatment and any benefit that is arising therefrom, or associated therewith to the in-
patient treatment. Please refer to item 7 for more details.

Page 4 of 7 Policy No. 600-0066305 Expiry Date: 03/29/2023

Created Date: 01/28/2023 Printed Date: 01/31/2023 Date of Next Insurance Age: Principal Insured: 07/21/2023
Version Number: 3.10.15
Plan Code: GHX54
 Global Health Access
for: Wilfredo Mira, 67

7) Annual Deductible is applicable to the following eligible in-patient treatment benefits and any benefit that is arising therefrom or
associated therewith to any eligible in-patient treatment:
l Daily accommodation charges l Radiotherapy and chemotherapy (Cancer Treatment)

l Hospital charges l Kidney Dialysis Treatment

l Organ Transplant l Physiotherapy, Occupational Therapy and Speech Therapy

l Reconstructive surgery l Hormone Replacement Therapy^

l Surgical implants l Oral and Maxillofacial surgery^

l Companion accommodation l Local Road ambulance transport

l Cash benefit l Pre and post-natal complications^

l In-patient treatment for AIDS/HIV l New born accommodation

l In-patient rehabilitation l Psychiatric treatment

l Pre- and post-hospitalization Outpatient treatment l Hospice and palliative care

^If there is no in-patient treatment, the annual deductible will not apply. If there is an eligible in-patient treatment, the annual
deductible will apply to the in-patient treatment and the associated benefits.

8) Pre-existing condition* exclusion/limitations do not apply to Health screen/Executive check-up benefit.

Pre-existing condition(s) refers to any medical condition which during the two (2) years preceding the policy effective date, or
reinstatement date, or plan upgrade date, whichever date is later: (i) your insured person has been diagnosed; or, (ii) for which
your insured person has received medication, advice or treatment, or, (iii) which the policyholder and/or your insured person
should reasonably, based on our appointed independent medical practitioner’s opinion, have known about; or, (iv) for which your
insured person has experienced symptoms even if your insured person has not consulted a medical practitioner. There will be a
waiting period of one (1) year for pre-existing conditions.

For avoidance of doubt, if you did have any pre-existing condition(s) before joining, please declare on the relevant Application
form. Such pre-existing condition(s) will also be subject to medical underwriting and if not disclosed they may not be covered
under this policy.
9) Treatment of Pre-Existing Conditions: COVERED FROM DAY 1 IF QUALIFIED TAKEOVER

Takeover is defined by a transfer from a similar plan which the insured has been covered with for at least 365 consecutive days.
The insured’s prior plan should have similar plan limits, benefits and area of cover and the insured should pass AXA Philippines
underwriting qualification.

10) Nontakeover plans will have an applicable waiting period of 12 consecutive months for the following acquired medical conditions
and their associated medical conditions:
1. Cancer 2. Hepatitis B 3. Hepatitis C
4. Diabetes 5. Heart Disease 6. Kidney Failure
7. High Blood Pressure 8. Chronic obstructive pulmonary disease 9. Liver cirrhosis
10. Stroke/Cerebrovascular accident 11. Transient ischaemic attack

11) Premium rates of Global Health Access are not guaranteed. Subject to approval of the Insurance Commission, AXA Philippines
reserves the right to change all or any part of this policy that will be issued including the Benefits Table and/or any of the terms
and conditions.

12) Premium of Global Health Access will be adjusted based on the attained age of the insured on each policy anniversary and
according to the prevailing premium rates at the time of renewal. You may refer to your Financial Executive/Financial Advisor or
AXA for more information on renewal premium.

Page 5 of 7 Policy No. 600-0066305 Expiry Date: 03/29/2023

Created Date: 01/28/2023 Printed Date: 01/31/2023 Date of Next Insurance Age: Principal Insured: 07/21/2023
Version Number: 3.10.15
Plan Code: GHX54
 Global Health Access
for: Wilfredo Mira, 67

Exclusions and Limitations:

Listed below are some exclusions and limitations related to Global Health Access. This list is not exhaustive.
The complete list of Exclusions and Limitations is detailed in the policy contract that will be issued for this
product:

· Any charges for treatment related to and/or of congenital conditions;

· Pre-existing conditions as defined including any associated medical condition(s) or complications or consequential conditions
arising therefrom and conditions which were not disclosed to the Company before the period of insurance, date of plan upgrade
or reinstatement date whichever is later unless this has been agreed and accepted in writing by us;
· Under the ‘Pre- and post- natal complications’ benefit, we will pay for treatment of a medical condition which is due to and occurs
during the pregnancy. However we will not pay for such treatment if the pregnancy was a result of assisted means or any form of
assisted conception/assisted pregnancy or elective/non-medically necessary caesarean section;
· Treatment begun, or for which the need had arisen, during the first ninety (90) days after birth for any child conceived by artificial
means or any form of assisted conception/assisted pregnancy;
· Treatment of, or related to, prematurity or any consequence of it;
· Foetal surgery. By this we mean treatment given or undertaken on a foetus while in the womb;
· Termination of pregnancy or any consequences of it, except where eligible under the ‘Pre- and post-natal complications’ benefit;
· Contraception, investigations into and treatment of infertility, treatment designed to increase fertility (including treatment to prevent
future miscarriage), investigation into miscarriage and assisted conception/assisted pregnancy, sterilisation (or its reversal) or any
consequence of any of them or of any treatment for them;
· Treatment of impotence or varicocele or any of their consequence;
· Treatment of, or related to, sexual dysfunction or any consequence of it;
· Treatment of sexually transmitted diseases;
· The costs of collecting donor organs or tissue or any administration costs (such as, but limited to, the cost of donor search) even if
such transplants are allowed by the terms of this policy;
· Treatment which arises from or is directly or indirectly caused by a self-inflicted injury or an attempt at suicide;
· Any treatment to correct refractive defects of the eyes such as long or short-sightedness or astigmatism, unless allowed for by the
insured person’s plan; laser/lasik eye surgery;
· Any additional hospital charges for a non-standard single room (for in-patient/day-care treatment outside the Philippines) or in a
single room that exceeds the limits stated in the benefits table applicable to the insured person’s plan (for in-patient/day-care
treatment in the Philippines), luxury menu items, menu items not included as standard, visitor’s meals;
· The costs of providing or fitting any external prosthesis or orthosis or appliance or medical aids or durable medical equipment or
mobility aids;
· Orthodontics, periodontics, endodontics, preventative dentistry, and general dental care including fillings, no matter who gives the
treatment unless allowed for by your insured person’s plan stated in the benefits table;
· Dental implants;
· Claims if your insured person has travelled outside his/her area of cover to get treatment (whether or not that was the only reason)
or travelled against medical advice even if it is within the area of cover;
· Treatment incurred as a result of engaging in or training for any sport for which your insured person receives a salary or monetary
reimbursement, including grants or sponsorship (unless your insured person receives travel costs only);
· Treatment of injuries sustained from racing of any kind (except foot racing), motorcycling (except daily use for transportation on a
paved road), base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering
with or without the use of ropes or other equipment, polo, steeplechasing, rugby, boxing, wrestling, caving, scuba diving to a depth
of more than 10 meters, trekking to a height of over 2,500 meters, bungee jumping, canyoning, hang gliding, paragliding or
microlighting, parachuting, skydiving, parasailing, potholing, skiing off piste or any other winter sports activity carried out off piste or
any dangerous or hazardous activities unless declared and accepted by the Company;
· Any claim or part of a claim in respect of which you/your insured person have to pay an excess (or deductible or co-insurance). In
this case we will only pay the balance of the claim after we have deducted the excess (or deductible or co-insurance) amount; any
claim which is within the waiting period;
· Any charges made by medical practitioner, hospital, laboratory or any such medical services which are not reasonable and
customary;
· All bank or credit charges when the claims payment is made in a currency other than Philippine Pesos; foreign exchange losses;
· Nutritional supplements including but not limited to special infant formula and cosmetic products even if medically recommended
or prescribed or acknowledged as having therapeutic effects;
· Cryopreservation, or harvesting or storage of stem cells as a preventive measure against possible disease/illness/injury or
implantation or re-implantation of living cells or living tissue, whether autologous or provided by a donor;
· Treatment which is not considered medically necessary or which may be considered as a matter of personal choice;
· Toiletries such as, but not limited to, shampoos, soaps, toothpastes, mouthwash, lotions, moisturiser, cleansers, shower gels,
contraceptives, proprietary headache and cold cures, artificial tears drop/gel, with or without prescriptions, nor do we pay for
telephone calls;
· Artificial life maintenance for more than sixty (60) continuous days if the insured person is only being kept alive by medical
intervention such as mechanical ventilation;

This proposal is an illustration only of the key features of the recommended insurance plan. You should refer
to your Financial Executive/Financial Advisor or the Company for more information. If your application is
accepted, you will receive a policy contract which will include detailed terms, conditions and exclusions.
Page 6 of 7 Policy No. 600-0066305 Expiry Date: 03/29/2023
Created Date: 01/28/2023 Printed Date: 01/31/2023 Date of Next Insurance Age: Principal Insured: 07/21/2023
Version Number: 3.10.15
Plan Code: GHX54
 Global Health Access
for: Wilfredo Mira, 67

DECLARATIONS AND ACKNOWLEDGEMENTS

Declarations
1. I confirm having read and understood the information contained in the Benefits Table Section, Notes
Section and Exclusions and Limitations Section of this illustration.
2. It is my understanding that the total premium I am going to pay when I purchase this plan shall consist of
the Global Health Access premium shown above.
3. I confirm having read and understood the information in this illustration. My Financial Advisor/Financial
Executive fully explained to me the benefits, feature and, exclusions and limitations related to the Global
Health Access product.
Product Transparency Declaration
By signing off on the items listed below, I acknowledge that the same have been discussed with and
thoroughly explained to me.

· I understand that I am buying a health insurance product.

· I understand that certain conditions may not be payable under the plan, as illustrated in the Exclusions
and Limitations of this proposal and detailed in the Exclusions and Limitations section of the policy
contract. This includes conditions that will not be payable during the waiting periods for certain medical
conditions and their associated medical conditions.
· I agree to answer all underwriting questions in the application form truthfully and I understand that
any mis-statement of facts, whether by commission or by omission may be grounds for AXA, in its
absolute and sole discretion, to decline to pay any benefit under the policy and also, to void the policy.
· I understand that the premiums will change according to any of the insured persons’ attained ages on
renewal. The premiums shown in this proposal are those currently in effect, but the premiums may
change upon renewal of the plan and will depend on those in effect at the date of renewal.
· I understand that due to the nature of the product AXA has the right to change the premiums of the policy
at any policy anniversary.
· I also understand that AXA has the right to change all or any part of the policy to be issued from any policy
anniversary and that AXA can change all or any part of the policy including the benefits table or the policy
terms, but only for the reasons shown in the policy document, and the changes will only apply when the
policy is renewed unless AXA is obliged by law to apply any change with immediate effect.
CONFORME: These declarations and acknowledgements are made
with the knowledge of AXA representative whose
signature appears below:

WILFREDO MIRA
Financial Advisor/Financial
Applicant/Policy Owner Date Date
Executive
Signature over Printed Name
Signature over Printed Name
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, and 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. Please carefully read the policy
and endorsements and consider the risks, charges and expenses before buying the policy. You should seek
professional advice from your financial, tax, accounting or legal consultant before buying the policy.
THIS FINANCIAL PRODUCT OF AXA PHILIPPINES IS NOT INSURED BY THE PHILIPPINE DEPOSIT
INSURANCE CORPORATION (PDIC) AND IS NOT GUARANTEED BY METROBANK OR PS BANK.

Page 7 of 7 Policy No. 600-0066305 Expiry Date: 03/29/2023

Created Date: 01/28/2023 Printed Date: 01/31/2023 Date of Next Insurance Age: Principal Insured: 07/21/2023
Version Number: 3.10.15
Plan Code: GHX54
 Reference Number: 53248-202301280313-2-04

FINANCIAL UNDERSTANDING SUMMARY

Dear WILFREDO,

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 101,340.00, and after taking into consideration your objectives,
risk profile and priorities, you have selected Global Health Access Gold Lite Plus Worldwide ex
USA for your Health need.

The details of your insurance coverage and your insurance premium are summarized in your
Global Health Access Gold Lite Plus Worldwide ex USA sales illustration.

DECOMOTAN, RYAN PAUL B

20780
53248
639615147058

This document is not intended to be a part of your 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: 600-0066305

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: 600-0066305

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

WILFREDO MIRA
Name and Signature of Proposed Insured

Signed in the Philippines - ANGONO

RIZAL
Date of Signing: 01-31-2023 05:44 PM

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.