APPLICATION NO.

__________________

PART I – APPLICATION FOR LIFE INSURANCE

PROPOSED INSURED INFORMATION
1. Last Name, First Name, Middle Name Other names (Maiden Name, alias, etc.)

Salutation  Mr.  Mrs. Mother’s Maiden Name: Birth date (MM/DD/YYYY) Birthplace
 Ms.  Others:____
Status  Single  Married Sex Age Nationality Self-Declaration US TIN / SSS No.
 Annulled  Widowed  Male Statement (for US Citizens)
 Legally Separated  Female  I acknowledge that I
am a United States
Citizen
Residence Address: Zip Code Telephone Number

Permanent Address: Zip Code Telephone Number

Email Address: Mobile Number:

2. Name of employer/Business Nature of Business Occupation/Position Nature of work (describe duties)

Office Address

Source of Income SSS/GSIS TIN Alien Certificate of Reg. (ACR)/I-Card #

Average Monthly Income from Employment/Business/Investments ACR/I-Card Date of Issue (MM/DD/YYYY)

3. Preferred Mailing Address  Residence Address  Permanent Address  Office Address

OWNER/PAYOR INFORMATION (If different from Proposed Insured)
4. Last Name, First Name, Middle Name Other names (Maiden Name, alias, etc.)

Salutation  Mr.  Mrs. Mother’s Maiden Name: Birth date Birthplace: Relationship of Policy
 Ms.  Others:____ (MM/DD/YYYY) Owner to Insured

Status  Single  Married Sex Age Nationality Self-Declaration US TIN / SSS No.
 Annulled  Widowed  Male Statement (for US Citizens)
 Legally Separated  Female  I acknowledge that I
am a United States
Citizen
Residence Address: Zip Code Telephone Number

Permanent Address: Zip Code Telephone Number

Email Address: Mobile Number:

5. Name of employer/Business Nature of Business Occupation/Position Nature of work (describe duties)

Office Address

Source of Income SSS/GSIS TIN Alien Certificate of Reg. (ACR)/I-Card #

Average Monthly Income from Employment/Business/Investments ACR/I-Card Date of Issue (MM/DD/YYYY)

6. Preferred Mailing Address  Residence Address  Permanent Address  Office Address

Page 1 of 12 Form no. IND-2019

 APPLICATION NO.__________________

FINANCIAL INFORMATION
7. a. Purpose of Insurance b. Other Source of Funds d. Method of Payment
 Personal/Family Protection  Employment Salary  Check Payment
 Key man Insurance  Business  Over the Counter (bills payment)
 Educational Expenses  Donations  Auto Debit Account
 Creditor’s Insurance  Others:_____________  Others :_____________________
 Retirement Income c. Mode of Payment e. Details of Initial Payment
 Investment  Annual Amount of Deposit :_______________
 Estate Conservation  Semi Annual
Agent’s Provisional Receipt No. :_______________
 Others: _______________  Quarterly
Agent’s Provisional Receipt Date :_______________
 Others:_____________
Official Receipt No :_______________
Official Receipt Date :_______________
PLAN INFORMATION
8. a. Plan for Traditional Plans:
________________________________ d. Dividend Option (for Participating policies)
b. Sum Assured  Paid in cash
________________________________  Used to reduce premium
c. Additional Benefits/Riders  Used to buy Paid Up Insurance
 Left to accumulate at interest*
 Waiver of Premium due to disability *Applies if no option is chosen
 Accidental Death Benefit
 Return of Premium e. Premium Default Option
 Payor’s Benefit for Death or Disability  Premium Loan
 Others: ______________________  Net Surrender Value
 Paid Up Insurance**
**Applies if no option is chosen
for Variable Plans:
f. Fund Allocation h. Top-Up Amount:_______________________
 ALGA Equity Opportunity Fund _____________%  Lump sum
 ALGA Philippine Balanced Fund _____________%  Regular
 ALGA Philippine Fixed Income Fund _____________%
 Others:______________________ _____________%
Total 100%
9. BENEFICIARIES (If more than one is named, equal shares shall be assumed unless otherwise stated)

 In case of death of the Insured, the surviving PRIMARY (P)  A CONTINGENT beneficiary designation is always
beneficiaries shall receive the death benefit considered revocable
 Should all the PRIMARY beneficiaries die before the Insured,  If the Insured did not indicate the designation of his/her
the CONTINGENT (C) beneficiary, if any, shall receive the beneficiaries, default designation will be ‘PRIMARY’
death benefit and/or ‘REVOCABLE’
 A PRIMARY beneficiary may be designated REVOCABLE (R) or  If a beneficiary is still a minor at the time of benefit
IRREVOCABLE (I) beneficiary. If the beneficiary designation is payment, his representative must secure and submit a
IRREVOCABLE, the Owner cannot change the beneficiary nor court-approved letter of Guardianship including a
exercise any right under the policy without the consent of the Guardian’s Bond in accordance to Section 182 of the
irrevocably designated beneficiary. Unless otherwise stated, Amended Insurance Code
the PRIMARY beneficiaries shall share equally in the
insurance proceeds

Relationship to Date of % of Share

Names (P) (C) (R) (I)
Proposed Insured Birth in Proceeds
   
   
   
   
   
   
CROSS OUT empty boxes below your last beneficiary entry

Page 2 of 12 Form no. IND-2019

 APPLICATION NO.__________________

Proposed Owner/ Please give full details in the

10. Declarations of the PROPOSED INSURED Insured Payor space below. Use additional
(and other if Owners Benefit is applied for)
YES NO YES NO sheets, if necessary
a. Have you, within the last 5 years, ever been confined or
treated by a physician or other medical practitioner for any
disease of the brain or nervous system, lungs or respiratory
system, heart or circulatory system, stomach or digestive
   
system, kidney or urinary system, or reproductive system,
including HIV? If ‘YES’ please provide full details in the
space provided.

b. Do you or did you have other illness/injury not mentioned

above? If ‘YES’ please provide full details.    

c. Are you in good health and free from any signs or

symptoms of disease and without any physical
impairments? If ‘NO’ please provide details, include dates,    
diagnosis, names and addresses of physicians, hospitals,
clinic, etc.
d. Do you smoke cigarettes/cigars? If ‘YES’ how many sticks per
day ___ and number of years have you been smoking? ____    

e. Have you had any change on weight in the last 12 months?

   
If YES, from _____ lbs/kg to ______ lbs/kg
Present height (Proposed Insured) :_____ cm.or _____ft. in.
Present weight (Proposed Insured) :_____ kg. or _____lbs.
Present height (Owner / Payor) :_____ cm.or _____ft. in.
Present weight (Owner / Payor) :_____ kg. or _____lbs.

f. Have you ever had an insurance or reinstatement of

insurance on your life declined, postponed or modified in
   
amount plan or rate? If ‘YES’ please specify which
insurance company, when and why?
g. Do you intend to change residence or work abroad within
   
the next 12 months? If ‘YES’, where?
h. Have you or any of your immediate family members been
appointed or elected to a position in the Philippines or in a
foreign state, as a politician, judicial or military official,    
senior executive of government or state-owned or
controlled corporations or political party official?
i. Do you engage in motorcycle, auto or motorboat racing,
skydiving, scuba diving or hazardous avocation? Or have
   
you ever flown in an aircraft other than a commercial
plane? If ‘YES’ please give details in the space provided
j. Have you been involved or included in any lawsuit or court
litigation? If ‘YES’ please state the reason (indicate the
nature of case, involvement and status),    
Plaintiff/Complainant, Defendant/Accused, and Status of
the Legal Case
k. FOR FEMALE ONLY: Are you pregnant?    
If yes, how many months? ____________
Are there any complications?    
Please make sure that all fields that require full details are completely filled out

Page 3 of 12 Form no. IND-2019

 APPLICATION NO.__________________

11. DECLARATION
A. FOR THE PROPOSED INSURED
i. Total life insurance in force on proposed insured
Company Basic Cover Accident Rider Year of Issue

ii. Has there been or will there be any change in existing insurance inforce? Yes  No 
iii. Will premiums for the insurance applied for be paid by a policy loan from existing policy? Yes  No 
If answer is yes to questions ii and iii, please furnish details as follows:
Company Policy Number Effective Date (MM/DD/YYYY) Amount of Coverage

REMINDER: It is usually disadvantageous to REPLACE existing life insurance policies with a new one. Some
disadvantages are:
 You may not be insurable in standard terms
 You may have to pay a higher premium in view of higher age
 You may lose financial benefits accumulated over the years.
Please note that in your own interest, we would advise that you consult your present insurer before making a final
decision. Hear from both sides and make a careful comparison. You can then be sure that you are making a decision
that is in your best interest.

B. FOR THE AGENT

i. Has there been or will there be any change in existing insurance inforce on the life of the Proposed Insured? Yes  No 
ii. Will premiums for the insurance applied for be paid by a policy loan from existing policy? Yes  No 
If YES, have the applicant complete a Replacement Notification Form

12. HOME OFFICE ENDORSEMENTS

I/WE HEREBY DECLARE AND AGREE THAT:

1. This insurance is issued on the above answers and questions which I/we represent to be true and complete to the best of
my/our knowledge and belief
2. The policy will not become effective until I/we have paid the entire first modal premium, and the policy delivered to
me/us while the insured is in good health
3. The date that Etiqa Life & General Assurance Philippines, Inc. (herein called “the Company”) receives the premium is the
latest of the following dates:
a. The official receipt date
b. The date any non-local check or other form of payment is cleared
c. The date the Company receives complete requirements; or
d. The date the Company receives my/our acceptance of the non-standard terms.
4. For premium payments made through a soliciting agent, the date of the Official Receipt issued by the Company will govern,
not the date of Agent’s Provisional Receipt.

Page 4 of 12 Form no. IND-2019

 APPLICATION NO.__________________

5. We understand that as a financial institution, the Company is subject to existing and future government regulations. I/We
therefore agree to be bound by all applicable domestic and international laws in relation to any matter including but not
limited to anti-money laundering, tax monitoring and data privacy.
In this connection, I/We hereby authorize the Company to process my/our personal and sensitive information including
but not limited to its collection, use, disclosure or destruction, I/We likewise give my/our consent to the Company to share
such information to its subsidiaries, affiliates, agents and any medical information sharing facility of the insurance industry
for any legitimate purposes, including but not limited to underwriting and administration of insurance coverage and claims
and provision of any product, service or others.

VARIABLE LIFE INSURANCE DECLARATIONS

6. If the Company receives my/our application and premium before the application cut-off time, the Company will use the
unit price for that pricing date to buy units in my/our account. Otherwise, if received after the applicable cut-off date, the
Company will use the unit price for the following pricing date. The Company has the sole discretion in determining the
frequency of valuation, but said valuation will not be less frequent than weekly. The price for a particular pricing date will
only be known at least one business day after the pricing date.
7. For VUL transactions, the cut-off time specified in item 3 will be followed in determining the unit price.
8. For payments made through banks, over-the-counter or online, any unmatched information in the deposit slip/payment
slip/online transaction details may cause delay in premium allocation. The unit price prevailing at the time when premiums
are properly applied becomes the applicable unit price
9. All charges will be deducted by selling the number of units equivalent to the amount of the charges as determined by the
Company.
10. When the unit price is calculated, an annual investment management charge will be deduct from the fund at a rate,
guaranteed not to exceed 2% per annum, to be disclosed by the Company,.
11. If this application is accepted and approved by Etiqa Life & General Assurance Philippines, Inc.and the corresponding policy
contract has been issued and I/we decide to return the policy within 15 days from the date of receipt of the policy contract
and provided no other transactions were made by me/us from the time of application for insurance, then the amount
refundable to me/us shall be the market value of the units plus insurance charges and initial or acquisition/administration
charges.
12. If the application is declined, the amount refundable to me/us shall be the full amount deposited after it has been
cleared.

MEDICAL INFORMATION DATABASE

13. “In accordance with the Insurance Commission's Circular Letter No. 2016-54, your medical information will be uploaded to
a Medical lnformation 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”

TAX DECLARATION
14. I/We declare that I/we have informed of all my/our citizenships, residencies and tax residencies, and provided my/our
taxpayer identification number(s). I/We agree to promptly update of any changes to said information. I/We authorize Etiqa
Life & General Assurance Philippines, Inc.to disclose my/our personal information to any government or tax authority
(within or outside the Philippines) for the purposes of ensuring compliance with applicable laws and regulations. I/We
agree that Etiqa Life & General Assurance Philippines, Inc. shall have the right to: (a) require the claimant(s) and/or payee(s)
of the Policy to provide with their above-mentioned personal information and/or sign such documents as 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 compliance with applicable laws and regulations. If I/we fail to any of the above-mentioned
acts, I/we agree that Etiqa Life & General Assurance Philippines, Inc.may provide my/our personal information to such
government or taxation authorities to comply with the applicable laws and regulations.

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.

Page 5 of 12 Form no. IND-2019

 APPLICATION NO.__________________

Before signing below, I have read the foregoing statements and answers and found them to be true and complete to the best of
my knowledge. I agree that such statements and answers shall be part of the Application and are made to induce Etiqa Life &
General Assurance Philippines, Inc. to issue policy applied for

Signed this ___________ day of ________________________ 20________ at ___________________________________________.

_______________________________ _______________________________ _______________________________

Witnessed by Owner/Payor Proposed Insured
(Signature over printed name) (Signature over printed name) (Signature over printed name)

_______________________________ _______________________________ _______________________________

Soliciting Agent Agent Code Parent/Guardian
(Signature over printed name) (if insured is below 18 years old)
(Signature over printed name)

________________________ ________________________ ________________________ ________________________

Referrer Referrer Code Branch Branch Code

AUTHORIZATION TO RELEASE RECORDS AND INFORMATION

I hereby consent and authorize that:

1. Any physician, clinic, insurance company or other insurance industry association, institution or person that has any record
of me/or the proposed insured named in this application, may release or give to Etiqa Life & General Assurance
Philippines, Inc. its authorized representative any and all information about me and/or the proposed insured named in
this application;
2. Any information collected by Etiqa Life & General Assurance Philippines, Inc. may be released and/or disclosed to affiliated
companies and agents other insurance companies and their affiliates and any medical information sharing facility of the
insurance industry for any legitimate purpose, including but not limited to underwriting and administration of insurance
coverage and claims;
3. I and/or the proposed insured named in this application, may be subjected to HIV testing for the purpose of underwriting
this application of the coverage related to the insurance policy, if issued; AND
4. A personal investigation on me and/or the proposed insured named in this application may be conducted.

__________________________________________________ __________________________________________________
Printed Name and Signature of Payor/Applicant-Owner Printed Name and Signature of Proposed Insured

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 companies. 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 (PAMD) of the
Insurance Commission at 1071 United Nations Avenue, Manila with telephone number +632-5238461 and e-mail address
[email protected]. The official website of the Insurance Commission is www.insurance.gov.ph

Page 6 of 12 Form no. IND-2019

 APPLICATION NO.__________________

CLIENTS PROFILE QUESTIONNAIRE

What kind of investor are you?

Answer this questionnaire to find out. This questionnaire helps you determine your personal investment style. It gives you an idea of
your investment time frame, stages of life, financial situation, priorities and goals.
There are no right or wrong answers. This questionnaire is designed to help us recommend an asset allocation strategy based on your
stated needs. It is intended to be a general recommendation only and should not be treated as specific investment advice.
While your agent may provide you with factual information, you should make your fund allocation based on your own judgment and
personal circumstances.

GENERAL INFORMATION - Please fill in the information in PRINT

Name of Proposed Client (Last, First, Middle):

Contact Number: E-mail Address:

Mailing Address (No. Street, Town/City, Province, Country, Zip Code)

Approximate Net Worth  Under 1 Million  1-10 Million  over 10 Million

Most Important Investment Goal  Retirement  Education  Buying a House  Others, please specify:

Investment Objectives  Growth  Income  Income & Growth

Risk Tolerance  High  Medium  Low

Investment Knowledge  High  Average  Little  None

At what age would you like to retire?

How much do you think you would need to retire at this age?
How much have you set aside today for your retirement fund?
Please check all that apply I currently have I used to have
Life Insurance  
Government Securities  
Foreign Currency and Bank Deposit  
Comment or Private Trust Funds  
Real Estate  
Commodities/Futures/Options  
Pre-Need Plan  
Time Deposit  
Mutual Funds  
Corporate Bonds  
Stocks  
Own Business  
Do you have a plan for saving regularly? Please choose one
 Yes, I save a part of my income every month/quarter/year
 Yes, I save a part of my income whenever I can
 Yes, but I only save regularly if I have a definite project to pursue
 No

Page 7 of 12 Form no. IND-2019

 APPLICATION NO.__________________

YOUR PROFILE

To complete this questionnaire, please choose the statement which most closely defines your needs or best describes your
situation. Put a check in the bracket in the left hand margin that corresponds to your choice.
IMPORTANT: If some of your choices bear an asterisk (*) please note that a Variable Unit-Linked (VUL) Policy may not be an
appropriate investment for you as they are designed for long-term investing

Section 1 – Financial Goals

1. What is your primary goal in making this investment?
 (2) I am saving to buy a car, make a down payment on a house or to achieve some other goals within the next 7 years*
 (4) I am investing for the long-term (more than 7 years) but I need this investment to generate cash flow to supplement
my income.
 (8) I want an investment that will generate both income and long term capital growth without specific emphasis on
either.
 (10) I am looking primarily for long term growth. Although I have no need for income from this investment or over
the next ten years, I might appreciate that a small portion is to be invested in fixed-income securities for
stability
 (12) I am looking for long term growth only. I want to maximize my potential return
2. What percentage of this investment do you plan to spend in the next 7 years?
 (2) More than 50%
 (4) 30% to 50%
 (6) Less than 30%
 (8) I don’t plan to spend any of it
3. In how many years will you withdraw all or majority of this investment?
 (2) Less than 7 years
 (6) Between 7 and 10 years
 (10) Between 11 and 20 years
 (12) More than 20 years

Please add your score for Section 1 _________

Section 2 – Background Information (Please choose only one)

4. When are you planning to retire?
 (2) I am retired
 (4) In less than 7 years
 (6) In 7 to 10 years
 (10) In 11 to 20 years
 (12) More than 20 years
5. How old are you?
 (2) Over 65
 (6) 51 to 65
 (10) 36 to 50
 (12) 20 to 35
6. Which of the following statements best describes your employment situation?
 (2) My employment situation is somewhat unstable
 (2) I am either a homemaker, retired or unemployed and I will rely on this investment for current income and
emergency cash needs
 (4) My employment situation is currently stable but this could change
 (5) I am either a homemaker, retired or unemployed but I have other sources of income that are sufficient to meet my
normal requirements
 (9) My employment situation is stable and I don’t expect this to change in the near future
 (12) My employment situation is completely secure

Page 8 of 12 Form no. IND-2019

 APPLICATION NO.__________________

7. Which of the following statements best describes your financial situation? Please consider your regular expenses and your
ability to pay outstanding loans as well as a saving for retirement and emergencies?
 (2) My financial situation is somewhat unstable
 (2) I need this investment to supplement my income
 (5) I do not currently need this investment to supplement my income however this could change
 (8) I don’t expect to use this investment to meet current income requirements. However, should an unexpected
situation arise, I may need to access these funds
 (10) My financial situation is stable and I have sufficient cash flow to meet most of my requirements
 (12) My financial situation is completely secure and I can meet emergency requirements without withdrawing these
funds
8. Which of the following statements best describes your investment situation? (If you do not currently have any investments,
choose the response that best describes how you think you would manage your investment.)
 (2) All of my investments to date have been in Treasury Bill because I need the security of capital
 (5) Most of my investments were made to generate income and preserve capital but I now need some capital growth
 (7) Most of my investments tend to be mutual funds or common trust funds, although they are generally not
aggressive
 (10) Most of my investments tend to be moderately aggressive. My objectives are long term, therefore I don’t often make
changes unless my reason for investing have changed
 (12) I tend to choose aggressive investment funds for long term growth
Please add your score for Section 2 _________

Section 3 – Risk Tolerance (Please choose only one)

9. Which of the following statements best describes your attitude towards the level of risk or volatility that you are prepared to
live with during the time these assets will be invested
 (2) I am aware that the value of an investment fund fluctuates daily and to varying degrees depending on the type
of fund. I would feel most comfortable investing in funds that tend to generate a more stable return year-to-
year, as opposed to funds that fluctuate widely
 (5) I am comfortable with the fact that the value of my investment will fluctuate daily. However, I would prefer that
roughly half of my assets be invested in less volatile fixed income securities and that the balance be invested in
equities, which tend to be more volatile
 (8) I am comfortable with volatility and seek more aggressive investments knowing that in the short term, this
strategy may result in declined in value, but in the long term, I have better chance of realizing gains.
Nevertheless, I do worry when the stock market drops significantly
 (10) I fully accept volatility and seek more aggressive investments knowing that in the short term, this strategy may result
in declined in value, but in the long term, I have better chance of realizing gains
10. How much of a temporary decline (i.e. one year) in the value of your investment could you tolerate?
 (0) No decline
 (2) Up to 5% decline
 (5) 5% to 10% decline
 (8) 10% to 15% decline
 (12) More than 15% decline
11. Which of the following statement best describes your investment philosophy?
 (2) I am not comfortable taking risks with my capital but I am prepared to do so with a small portion of my assets
as I need some capital appreciation to offset inflation
 (4) I understand that the opportunity for greater returns comes with taking greater risks, but I am only prepared to do so
with less than half of my assets
 (6) I understand that the opportunity for greater returns comes with taking greater risks, and I am prepared to do
so with more than half of my assets
 (10) I have an aggressive investment approach and I am investing for the long term, therefore, I want to invest the
majority or even all of my assets in the stock markets, as this is the best way to ensure higher returns over the
long term
Please add your score for Section 3 _________

Page 9 of 12 Form no. IND-2019

 APPLICATION NO.__________________

Understanding Your Score

Please transfer your score for each section to the corresponding space and then carefully add up your total score

Score
Section 1 – Financial goals
Section 2 – Background Information
Section 3 – Risk Tolerance
TOTAL SCORE

Note: We strongly recommend you review your view point about investment risk at least once a year or when major change
occurs in your personal situation to make sure your investment decision continues to match your attitude towards
investment risk profile.

Conservative: A score of 60 points or less indicates that you are comfortable having your assets managed conservatively with an
emphasis on the stability that comes from fixed-income investments, while generating some capital appreciation over time. Your
investment horizon is short to moderate and your tolerance towards volatility is moderate. You seek capital preservation.

Moderate: Scoring between 61 and 84 points indicates that you are seeking long term capital appreciation and to a lesser extent, the
stability that comes from fixed-income investments. You are most comfortable with relatively stable year-to-year returns but will
accept some volatility as you understand that the capital growth you require cannot be achieved without some element of risk.

Growth-Oriented: Scoring between 85 and 120 points indicates that you are seeking long term capital appreciation with little or no
requirement from additional income. You can tolerate greater year-to-year volatility, as well as some moderate to strong fluctuations
in the capital value of your investment. You realize that overtime, equity markets usually outperform other investments.

By signing below, I acknowledge that:

1. this questionnaire does not constitute advice from the company, as it only intended as reference to help me assess my risk
appetite and investment objectives based on the information I have provided;
2. I am responsible for my investment decision, including my choice of fund, even if such varies with the results of this
questionnaire
3. my financial needs may change over time depending on my personal situation and objectives; and
4. the Company makes no guarantee as to the accuracy or completeness of the results or recommendations provided above.

__________________________________________________ __________________________________________________
Signature of Proposed Client Date (Day/Month/Year)

To be accomplished by your Agent

Name of Agent Agent Code Signature of Agent Date(Day/Month/Year)

Page 10 of 12 Form no. IND-2019

 APPLICATION NO.__________________

CONFIDENTIAL REPORT OF AGENT

To be accomplished by Agent
IMPORTANT: Please go over the entire application carefully and review the answer to each question. Unanswered or incompletely
answered questions will result in delay by the Home Office in taking final action on this application. Help yourself, the Proposed
Insured (PI)/Owner and the Company by careful, complete and accurate preparation of the application. The answers given by the
Proposed Insured/Owner form part of the policy contract and it is very necessary that the PI/Owner be asked such question. Be
specific. Do not use indefinite terms such as “just met”, “new contract”, “amply”, etc., and do not leave any questions unanswered

1. a. How long have you known the Owner? 9. What rating and premium have been quoted?
b. Are you related to PI? If yes, give relationship  Standard  Substandard
Rating Annual Other Mode
2. How much is the yearly income of PI? Php_______ Life (Regular) P A
Owner? Php______
Occupational SA
3. Do you know any information which might adversely affect
the underwriting of this risk? Explain fully WP Q
a. Any threat or attempted violence on PI or any
immediate family member? ADB M
b. Any involvement of PI in lawsuit or court litigation?
c. Any involvement of PI in political activities? Others x
d. Any homosexual or gay behavior of PI?
e. Any undesirable habits (gambling, smoking, drug Total P
abuse) of PI?
f. Any family history of heart or kidney disease, diabetes,
cancer, mental illness? OCCUPATIONAL HOBBIES
a. Describe his occupation and duties in detail
4. Does the appearance of the PI (and Owner of applicable)
indicate good health? If not, explain why.
b. Describe his hobbies and extent to which he indulges in
5. Is the insurance applied for intended to take the place of them
insurance carried in this or any other company? If so, give
details: MORAL
a. Give details of his activities, usual and unusual
6. Information regarding travelling activities to combat zones
in the world, and frequency of travels to Regions IX and XII
b. Give details of any known incidents or conditions that
7. PI/Owner has been or will be examined by: may endanger his life, like threats or illicit relations with
Dr. on the opposite sex
And (if two examinations or required)
Dr. on
c. Is he a frequent heavy drinker or user of a dangerous or
8. If PI is below 18 years old: prohibited drugs?
a. How many siblings does the proposed insured have?
How many are insured?
If some are not, explain why. FINANCIAL STANDING
a. Explain any serious embarrassing financial problems
b. Insurance in favor or applied for on life of siblings?
Insurance Year insured
Name Amount b. Does he have any heavy debts or is his credit standing
Company or Applied for
questionable? If so, explain fully

HEALTH
Give details of hospitalization, accidents, or serious illness
suffered by the PI during the last 5 years. Give names and
addresses of attending physician

Page 11 of 12 Form no. IND-2019

 APPLICATION NO.__________________

Additional or Explanatory Remarks and details of answers to Questions 1 to 7

I/We certify that I/We personally saw the PI and Owner, if applicable.

________________________ ________________________ ________________________ ________________________

Signature of Agent Name of Agent Code No Mailing Address

________________________ ________________________ ________________________ ________________________

Signature of Agent Name of Agent Code No Mailing Address

To be filled by agents authorized for non-medical insurance

NON-MEDICAL AUTHORITY Application Received &Reviewed by: C/A & Agent’s Code No. Verified By:

Date of Authority Print Name Print Name

Agent’s Signature Signature Signature

(Certified Correct)

Date Date

Page 12 of 12 Form no. IND-2019