Policy Number

311 - 4924214

Application Number R 32886-202008150714-3-02

Traditional Variable Multiple Application

Application for Life Insurance of

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

1. DETAILS OF PROPOSED INSURED

LAST NAME
TURCULAS
FIRST NAME Notes

LORADEL Please accomplish as

well the “Proposed Owner
MIDDLE NAME Details” section at the
back page if the Proposed
Owner is different from
MACABIDANG the Proposed Insured.

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

SEX CIVIL STATUS
is an individual who is or has
SAMAR Male Female
1976/10/15 Single Married Widow Divorced/Annulled been entrusted with prominent
public positions in the Philippines
with substantial authority over
policy, operations, or the use or
allocation of government-owned
NATURE OF OCCUPATION/BUSINESS SPECIFIC OCCUPATION IDENTITY NO. (TIN, SSS or GSIS) resources; or a foreign state or
NURSE Nurse Other: CRN-006-0070-9709-4 international organization,
including heads of state or of
NATIONALITY government, senior politicians,
senior national, or local
ARE YOU AND/OR YOUR IMMEDIATE FAMILY A POLITICALLY EXPOSED PERSON (PEP)? Yes No Philippines government, judicial or military
(If yes, please specify government position/public office)
officials, senior executives of
government or state-owned or
IF WORKING ABROAD, STATE THE CITY/PROVINCE AND COUNTRY controlled corporations and
important political party
RESIDENCE/PRESENT ADDRESS officials.
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province)
ZIP CODE
83 NCMH HOUSING NUEVE DE PEBRERO ST MANDALUTYONG CITY
1550
Residence Address should
be a Philippine Address
PERMANENT ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS) (in reference to
Cross-Border Rule)
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province)
ZIP CODE
Residence Address shall
83 NCMH HOUSING NUEVE DE PEBRERO ST MANDALUTYONG CITY
1550 be used as default mailing
address

BUSINESS ADDRESS
Unless you are a bank
BUSINESS NAME/NAME OF EMPLOYER (Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE employee, Bank address
and contact information
NKTI NKTI EAST AVE DILIMAN QUEZON CITY 1100 should not be used

PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business

CONTACT INFORMATION
HOME PHONE NUMBER MOBILE NUMBER (Mandatory)
0 639568666663

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory) Answer this question only
if Proposed Insured is the
0 [email protected] same as the Proposed
Owner
SOURCE OF FUNDS/MONTHLY INCOME
Salaries/Php 30000.00 Income from business/Php Savings/Php 300000.00

Maturing Investment/Php Others:

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

(If yes, please provide US TIN/SSN)

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Application for Life Insurance Application Number R 32886-202008150714-3-02

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

LAST NAME
Notes

FIRST NAME Accomplish only if

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

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

IF WORKING ABROAD, STATE THE CITY PROVINCE AND COUNTRY

RESIDENCE/PRESENT ADDRESS
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE

Residence Address should be

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

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

PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business

CONTACT INFORMATION
HOME PHONE NUMBER MOBILE NUMBER (Mandatory)

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

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

BENEFICIAL OWNER (If any)

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

NATURE OF BUSINESS FULL NAME OF AUTHORIZED SIGNATORY

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

CONTACT INFORMATION OF AUTHORIZED SIGNATORY

MOBILE NUMBER (Mandatory) BUSINESS ADDRESS

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

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4. BENEFICIARY DESIGNATION Notes

*TYPE OF IRREVOCABLE
NAME PRESENT PLACE OF DATE OF NATURE OF RELATIONSHIP BENEFIT BENEFICIARY (Please shade if Surviving Beneficiaries in
(Last, First, Middle Name) ADDRESS BIRTH BIRTH WORK TO PROPOSED % (optional) Irrevocable the same classification
Beneficiary)
INSURED Primary Secondary will equally share in the
benefits.
83 NCMH HOUSING NUEVE DE
JIMENEZ, JOHN MANDALUYO
PEBRERO ST MANDALUTYONG 1997/11/07 Student Child 100 Designation of a minor as
CHRISTOPHER TURCULAS NG
CITY
Irrevocable beneficiary
is discouraged.

5. BASIC PLAN DETAILS Secondary Beneficiaries

are entitled to the benefits
if no Primary Beneficiary
BASIC SUM INSURED SINGLE PREMIUM survives
PREMIUM TYPE CURRENCY
Regular-Pay Single-Pay Peso Dollar When policy owner (PO)
1,000,000.00 designates a revocable
beneficiary, the PO may change
PLAN NAME PAYMENT TERM, If applicable YEARS TO MATURE, If applicable the policy details, including its
beneficiaries, any time.
FlexiProtect Life Regular Premium However, when PO designates
irrevocable beneficiary, PO
PURPOSE OF THE INSURANCE APPLIED FOR: may not change the details of
the policy, without prior
Income protection Retirement planning Business continuation/ Keyman insurance Fringe benefit
consent of said irrevocable
Children’s protection Education funding Outstanding mortgage loan Estate planning beneficiary.

(Beneficiaries are preferably “irrevocable”)

Savings Others
Single Premium refers
to a single one-off
payment that covers
6. SUPPLEMENT DETAILS the entire cost of
the Policy.

Secure (AD&D) Critical Illness Protector (Term)

RIDER SUM INSURED RIDER SUM INSURED RIDER SUM INSURED

YRT 20YRT UP TO AGE 55 YRT 20YRT UP TO AGE 55 YRT 5YRT 10YRT

5 PAY 10 PAY 20YRT UP TO AGE 55

5 PAY 10 PAY 5 PAY 10 PAY

20 PAY 20 PAY UP TO AGE 55

Waiver of Premium Care (Hospital Income) YRT 20YRT UP TO AGE 55

Selection of “Waiver of
Economy Superior Economy Superior Premier Premium” or “Payor’s
Payor's Clause Regular Premier Clause” as policy
supplement applies
to the basic and
Others Rider Name Rider Sum Insured supplement riders
where it is applicable
Rider Name Rider Sum Insured

7. CONVERSION OF TERM INSURANCE Applicable only for term

products with conversion
Conversion of Term Insurance is when all or some of your term life insurance policy or rider/s are converted into a permanent life insurance policy or rider/s. provisions.

* For Individual, Basic Term or Term rider plans

Policy No*./Certificate No**. Billing cycle: policies with
** For Group Term plans 1-15 as Effective Date shall be
charged every 5th of the
month while those with
16-28 as Effective Date
shall be charged every 20th of
8. PAYMENT INSTRUCTIONS the month. For rejected
billings due to insufficient
MODE OF PAYMENT METHOD OF PAYMENT balance, we will initiate
rebilling efforts in an
Annual Semi-annual Auto-Debit Arrangement (ADA) Credit Card Cash objective to keep your
policy in-force.
Quarterly Monthly Post Dated Check (PDC) Initial premium Recurring Others:
Policies with IIE feature and
enrolled in ADA/CC
(for Traditional will automatically be charged
9. DIVIDENDS/ENDOWMENTS AND PREMIUM DEFAULT OPTIONS products only) with the applicable IIE
premium on the 2nd policy
year.
* DIVIDEND/ENDOWMENTS OPTIONS ** PREMIUM PAYMENT DEFAULT OPTION
Requests for cancellation of
Accumulate with Interest Extended Term Insurance (ETI) ADA/CC payments should
be submitted 30 days prior to
Apply to premiums Reduced Paid Up (RPU) the scheduled debit/ charge
date.
Pay in cash Automatic Premium Loan (APL)
Requests for PDC pull-out
should be received at least
* By default, if no Dividend/Endowment Options is selected, below ** By default, if no Premium Option is selected, below will apply: 5 working days before the
will apply: Accumulate with Interest ETI – for standard cases; RPU – for substandard cases check maturity date.

Credit card payment is

NOT allowed for Single
Premium policies

All fund allocations

should total to 100%

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10. DETAILS FOR VARIABLE INSURANCE

TOP-UP OPTIONS, If applicable DEATH BENEFIT OPTIONS, If applicable
Regular Annual Top-Up Level Increasing

Lump Sum Top-up Amount

FUND NAME % ALLOCATION FUND NAME % ALLOCATION

1. 4.

2. 5.

3. 6.

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11. DECLARATION OF PROPOSED INSURED and OWNER (If Payor’s Clause is applied for)

Proposed Insured Proposed Owner If "Yes", please

Other Insurance and Lifestyle Questions (Owner to answer if payor’s clause indicate details
is applied for)

1. Have you ever had an application for Life, Critical Illness, Medical or
Disability insurance that was:
a. modified, rated or offered with reduced face amount, declined or Yes No Yes No
postponed?
b. rejected for reinstatement or renewal due to health/medical reasons? Yes No Yes No

2. Have you ever made a claim for Accident, Medical care, Critical Illness or Yes No Yes No
other benefits?

3. Have you ever made a disability claim or are you presently receiving a Yes No Yes No
disability benefit?
4. Are you presently incapable for work? Yes No Yes No

5. Do you participate or intend to participate in any hazardous activities

related to your occupation or any recreational activities such as (but not Yes No Yes No
limited to): scuba diving, mountaineering or climbing, skydiving,
parachuting, hang-gliding, motor sports or aviation (excluding flying as a
passenger on a regular scheduled airline)?
6. Have you ever taken any habit forming drugs or narcotics, or been
Yes No Yes No
treated or counselled for a drug problem?
7. Do you consume alcoholic beverages? If yes, give type and number of Yes No Yes No
drinks per day and/or per week.
Have you smoked or used any of the following in the last twelve
8.
months?:
a. Cigarettes Yes No Yes No PI PO
b. e-cigarettes Yes No Yes No sticks/day
c. Vape Yes No Yes No no. of packets/day
d. Smokeless tobacco Yes No Yes No months/years
e. Never smoked Yes No Yes No ml per day (for vaping)

Medical Questions

1. Height 5'2"(ft. & in.) or 157(cm.) and weight 110lbs. or 49.8952kg.

a.Have you experienced any weight change in the last 12 months? If yes, please state Yes No Yes No
amount gained or lost (kg) and the reason for weight change.

2. Have you ever had signs or symptoms or been told that you have or have
had any of the following medical conditions:

a. Heart attack, chest pain, high blood pressure, stroke, high cholesterol, Yes No Yes No
or any heart/blood/vascular diseases.

b. Cancer (including melanoma), tumor or growth of any kind. Yes No Yes No

c. Diabetes, thyroid disease, metabolic or endocrine diseases. Yes No Yes No

d. Hepatitis B or C (including Hepatitis carrier), HIV infection, liver, Yes No Yes No

gallbladder, or any gastrointestinal diseases.

e. Kidney diseases, diseases of the genitourinary system, breast diseases, Yes No Yes No
or any reproductive organ diseases.

f. Any musculoskeletal diseases (including joint/bone diseases, arthritis) Yes No Yes No

or any auto-immune diseases (including lupus).

g. Eyes/ears/nose/throat diseases, or any respiratory diseases. Yes No Yes No

h. Epilepsy, head/brain injury, paralysis, psychiatric diseases or other Yes No Yes No

neurological diseases.

3. In the last 5 years, have you been diagnosed, tested positive or received
medical treatment or been prescribed medication for any condition Yes No Yes No
which has lasted longer than 7 days (other than for minor conditions
such as cold or flu)?

4. Are you currently receiving any medical treatment or intend seeking or

have been advised by a physician to seek medical treatment for any
Yes No Yes No
health conditions or waiting the results of any medical
tests/investigations?

5. Have your biological mother, father, brother(s) or sister(s) been

diagnosed, before age 60, with any of the following: cancer, heart Yes No Yes No
disease, stroke, diabetes or any other inherited conditions?
For Female Applicant Only
1. Are you currently pregnant? Yes No Yes No
If yes, how many months?
Expected delivery date

Disclosure: In accordance with the Insurance Commission’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.

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12. REPLACEMENT OF EXISTING LIFE INSURANCE POLICIES

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

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

13. DECLARATIONS AND AGREEMENT:

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

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on the policy that will be issued;

c. I/We fully understand that a variable life insurance product involves risk. Value of units in Investment Funds may rise or fall. The benefits payable
under such product are linked to the performance of the Investment Funds according to my Fund Allocation Instruction;
d. I/We fully understand that if this application is cancelled by written notice, signed and sent by me/us directly to and received by the New Business and
Underwriting Department of AXA Philippines before it is approved, I/we can refund all the premium deposits paid by me/us and received by AXA
Philippines. If such notice is received by the New Business and Underwriting Department of AXA Philippines after the application is approved, the
amount of refund shall be equal to the market value of its units including initial charges; and
e. I/We understand that I have the right to cancel the policy to be issued during the cooling-off period provided therein and obtain a refund equal to the
market value of units including the initial charges thereof by giving a written notice and returning the policy. Such notice must be signed and sent by
me/us directly to and received by Customer Experience of AXA Philippines within 15 days from my/our receipt of the policy.
18. In the event of the Insured’s death prior to his/her attaining the age of four (4) years and six (6) months:
a. the amount payable under the Policy shall be in accordance with the following schedule:
Age at Death Amount Payable (Variable Life Policy) Death Benefit Payable
(nearest birthday) (Traditional Life Policy)
Less than 6 months 50% of the Sum Insured, or the Account Value, whichever is higher 50% of the Sum Insured
1 year 60% of the Sum Insured, or the Account Value, whichever is higher 60% of the Sum Insured
2 years 70% of the Sum Insured, or the Account Value, whichever is higher 70% of the Sum Insured
3 years 80% of the Sum Insured, or the Account Value, whichever is higher 80% of the Sum Insured
4 years 90% of the Sum Insured, or the Account Value, whichever is higher 90% of the Sum Insured

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

14. TELEPHONE UNDERWRITING AUTHORIZATION

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

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

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

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

15. REQUEST FOR DIRECT CREDIT TO BANK ACCOUNT

Policy No.: Account type: Bank Name:

Peso account Dollar account Metrobank Others:

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

Account Name of payee: Relationship to owner

Spouse Child Parent Sibling

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

MAMRXXEXREG-1118 7 of 18
Application for Life Insurance Application Number R 32886-202008150714-3-02

**PLEASE DO NOT SIGN ON A BLANK FORM

Date of Signing: Place of Signing:

LORADEL TURCULAS
Signature (Proposed Insured) Signature (Proposed Owner)

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

Name of Advisor/FE: DE VERA, JOYLIN PAULA MENDOZA Name of Advisor/FE:

Code: Code:

43237 4 32886

Signature: Signature:

16. DISTRIBUTOR’S DECLARATION

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

Name of Advisor/FE: DE VERA, JOYLIN PAULA MENDOZA Name of Advisor/FE

Signature: Signature:

MAMRXXEXREG-1118 8 of 18
Application for Life Insurance Application Number R 32886-202008150714-3-02

17. CREDIT CARD AUTHORIZATION/AUTO-CHARGE ENROLLMENT

Please refer to the back page for the Declaration and Reminders of this application form

CURRENCY: PHP USD ONE-TIME CHARGE RECURRING PREMIUMS* Date:

*Succeeding premiums due will be automatically charged to the enrolled card no.

Account type: Visa Mastercard

Month Year

Credit Card Number Expiry date: /

Credit Card Company: Billing Address:

Cardholder's Name:

(Last Name) (First Name) (Middle Name)

Cardholder's Birthday: Name of Insured(s):

Mother's Maiden Name:

Contact Number(s) of
Cardholder:

Relationship of card holder to Owner of policy

Parent Spouse Sibling Child (To be signed by the Policy Owner if different from Cardholder)

Signature over printed name of Cardholder Signature over printed name of Policy Owner

I authorize AXA Philippines to charge my premiums to my credit card account as indicated in the Credit Card Enrollment Form. I understand that the Policy will not
be inforce until I have made the first premium payment. I hereby authorize AXA Philippines to initiate and the card company to effect, charge entries to my account
for payment of premiums due from the above-captioned policy. The Bank/card company is hereby authorized to disclose to AXA Philippines such information as
may be necessary to implement this payment arrangement. I understand that only the account’s cleared and available balance shall be charged. In the event that
there is insufficient balance, AXA Philippines may initiate debit charges against my credit card account as it deems necessary and at its sole discretion. If no payment
was charged from the account due to insufficient balance, termination of account or other reason as advised by the card company, AXA Philippines shall not consider
the premium due from the above policy to have been paid and AXA Philippines shall have the recourse to collect directly from me or terminate my policy should I fail
to settle the premium within the grace period. I further understand and agree that constant unsuccessful debiting of my account due to insufficiency of funds shall be
a valid ground for the immediate cancellation of this payment arrangement even without prior notice.
I also understand that I may withdraw from this premium payment arrangement effective 30 days after receipt by AXA Philippines of a written notice of withdrawal.
I agree to promptly inform AXA Philippines of any changes in my credit card information, e.g. new card number, new expiry date, etc. I understand that AXA
Philippines will effect the changes 30 days after my notice.
Reminders
1. Credit Card Number must be 16 digits.
2. Official Receipt date for succeeding payments shall be equal to the date when electronic payment posting is done, usually within 3 days from charge date.
3. Billing cycle: policies with 1-15 as Effective Date shall be charged every 5th of the month while those with 16-28 as Effective Date, shall be charged every
20th of the month. If the 5th or 20th falls on a holiday, the debit transaction will be done on the next banking day. For rejected billings due to insufficient
balance, we will initiate rebilling efforts in an objective to keep your policy inforce.
4. No premium notice shall be issued to policies enrolled in the Auto-charge facility.

MAMRXXEXREG-1118 9 of 18
Application for Life Insurance Application Number R 32886-202008150714-3-02

Application Number R32886-202008150714-3-02

TEMPORARY LIFE INSURANCE CERTIFICATE

There is temporary insurance on the life to be insured beginning on the date of signing by the Proposed Insured/Owner of the Application form bearing the same serial
number as this certificate, if all the following conditions are met: (1.) The first modal premium has been paid with the Application for which a Temporary Receipt is
issued; (2.) Questions stated on section no. 10 were answered “NO” and (3.) All other required questions of the Application form are answered completely and
truthfully. All conditions under this certificate are subject to the Provisions of the Policy the Proposed Insured and/or Owner has applied for.
LIMITATION ON AMOUNT OF INSURANCE
The insurance benefit on the death of the life insured pursuant to this certificate is the amount which AXA Philippines would have paid had the Policy applied for been
issued. AXA Philippines shall in no event pay, subject to the imposition of juvenile lien whenever applicable, no more than One Million Pesos (PhP1,000,000) or the
equivalent in US Dollars, based on the prevailing exchange rate at the time of death of the Proposed Insured. The maximum amount of PhP1,000,000 includes any
accidental death benefit, under all Temporary Life Insurance Certificates inforce in respect of the Proposed Insured. However, if the insurance benefit paid for by the
Proposed Insured exceeds the said maximum, the amount of excess premium, which will be determined proportionately to the Policy applied for, will be refunded. The
insurance benefit will be prorated among all the Temporary Life Insurance Certificates inforce on that Proposed Insured.
TERMINATION OF TEMPORARY LIFE INSURANCE COVERAGE ON THE LIFE INSURED WILL BE THE NEAREST OF THE FOLLOWING:
(a) The date a termination notice is sent by AXA Philippines to the Applicant;
(b) The date the policy is issued as a result of the Application being approved;
(c) The date of termination as requested by the Applicant;
(d) The date of death of the Proposed Insured; and
(e) Sixty (60) days after signing this Application.
SUICIDE: If the life insured dies by suicide, the pertinent provisions of the Insurance Code shall apply. Where no insurance money is payable, the amount paid with
the Application will be refunded. No Advisor/Financial Executive has the authority to modify the terms of this Certificate.

MAMRXXEXREG-1118 10 of 18
Application for Life Insurance Application Number R 32886-202008150714-3-02

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 [email protected].
The official website of the Insurance Commission is www.insurance.gov.ph.

MAMRXXEXREG-1118 11 of 18
 FlexiProtect Proposed Insured:
LORADEL MACABIDANG TURCULAS
Life (Age 44, Female)

Policy Owner or Payor:

LORADEL MACABIDANG TURCULAS
Age 44, Female

Dear LORADEL,

Thank you for your interest in AXA products. FlexiProtect Life is a term insurance product designed to provide protection for your loved ones
against the financial impact of your untimely demise. It is renewable every 5 years, and can be converted to any whole life plan should your
needs change in the future. This product has great flexibility and provides peace of mind at a very reasonable cost.

Life Protection
· Guaranteed death benefit equal to PHP 1,000,000.
· Coverage for 5 years that you may renew until age 74 even without evidence of insurability. The term of any such renewal will be 5
years, or the number of years on the Policy Anniversary on which the Insured is aged 75 nearest birthday, whichever is shorter.
· Option to convert to any permanent life insurance subject to AXA Philippines’ conversion policies at the time of conversion.
· Option to increase your insurance benefit on each policy anniversary at the rate of inflation with no medical or processing
requirements through the Index -linked Increase Endorsement (IIE) so you can be sure that the value of your benefits aligns with
future costs.
Supplemental benefits from riders that provide other forms of protection:
· CARE provides daily hospitalization benefit up to PHP 800/day, or up to PHP 1,600/day if under intensive care.

Basic Plan and Supplements Cover Up to Age* Sum Insured (PHP) Annual Premium (PHP)**
Basic
FlexiProtect 49 1,000,000 3,950.00
Supplements
CARE REGULAR 49 - 5,602.80
TOTAL INITIAL ANNUAL PREMIUM 9,552.80

SEMI-ANNUAL PREMIUM 4,967.46

QUARTERLY PREMIUM 2,579.26
MONTHLY PREMIUM 907.52
* Refers to termination age
** Premiums for the basic plan (FlexiProtect) are renewable every 5 years and will depend on the attained age of the Insured at renewal date. For the
premium term of the supplement/s, if any, please refer to the supplement definition indicated in the "Summary of the Riders Attached to this Proposal".

Page 12 of 18 of Proposal No. 32886-202008150714-3-02 Policy No: 3114924214

Printed on: 2/4/2021 05:03:36 PM Created on: 08/15/2020 Expiry Date: 10/14/2020
Version Number: 6.0.0 Date for Next Insurance Age: 04/15/2021
Plan Code: TR05/ Rider Code: MEB2
FlexiProtect Philippine Peso
for: LORADEL MACABIDANG TURCULAS, Female, 44, Non-smoker

· Below is the FlexiProtect basic premiums renewal schedule as of date, for your reference.

Duration Annual Premium

1-5 3,950.00
6 - 10 4,890.00
11 - 15 7,290.00
16 - 20 11,460.00
21 - 25 17,200.00
26 - 30 24,850.00
31 31,120.00

This proposal is only an illustration of the key features of your policy and does not form part of the contract. For complete terms,
conditions and limitations of the plan, please refer to your policy.

Again, thank you for your interest in AXA products. If you have questions, please call me at the number specified below, or call AXA Philippines
Customer Care Hotline at Tel. No. (02)85815-292 or (02)83231-292.

DE VERA, JOYLIN PAULA MENDOZA

43237
32886
639175055194

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 independent 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 13 of 18 of Proposal No. 32886-202008150714-3-02 Policy No: 3114924214

Printed on: 2/4/2021 05:03:37 PM Created on: 08/15/2020 Expiry Date: 10/14/2020
Version Number: 6.0.0 Date for Next Insurance Age: 04/15/2021
Plan Code: TR05/ Rider Code: MEB2
FlexiProtect Philippine Peso
for: LORADEL MACABIDANG TURCULAS, Female, 44, Non-smoker

Attached Supplements
Summary of the Riders Attached to this Proposal
1. CARE pays a specific amount to defray the cost of hospital confinement/admission due to sickness or injury, based on the following
schedule:

CONFINEMENT/ADMISSION BENEFITS
ECONOMY REGULAR SUPERIOR PREMIER
General Admission (up to 1,000 days) P300/day P800/day P1,200/day P2,000/day

Intensive Care (up to 120 days) P600/day P1,600/day P2,400/day P4,000/day

Regular, Superior and Premier plans are entitled to "No Claim" discount equivalent to 15% of the previous year's annual premium if the benefit is not
availed of within the first three(3) consecutive years immediately preceding the current policy year.

CARE Premiums are payable up to termination age and are renewable annually. The premium rate will depend on the attained age
of the Insured at renewal date. Below is a sample premium schedule for your reference:

Age Nearest Annual Premium Age Nearest Annual Premium

Birthday Birthday
44 5,602.80 60 6,963.60
45 5,713.20 65 10,219.60
46 5,731.60 70 20,940.00
47 5,753.44
48 5,775.28
49 5,797.12
50 5,819.04
51 5,840.88
52 5,862.72
53 5,884.56

We will not pay You any benefit under this Supplement if your Confinement shall result directly or indirectly from any of the following causes:

(1) sickness or disease of the Insured which was contracted and commenced within thirty (30) days from the Effective Date of this Supplement or date of
its last reinstatement; or
(2) hospitalizations arising from pre-existing conditions* as defined in this supplement, that are claimed within twelve months from the Effective Date of
this Supplement or date of its last reinstatement (whichever is later); or
(3) pregnancy, childbirth or miscarriage, sterilization or infertility and any other related treatment of congenital anomalies; or
(4) any drug or alcohol abuse; or
(5) any self-inflicted injury or suicide or any attempt thereat, whether sane or insane; or
(6) cosmetic surgery, eye glasses, corrective aids, and treatment of refractive errors or any optional surgery, unless as a result of Covered Injury; or
(7) dental surgery except as a result of covered injury; or
(8) general check-up, convalescence, custodial or rest care; or
(9) treatment or surgery for tonsils, adenoids or hernia or a disease peculiar to the female generative organs, unless the Insured has been continuously
covered under this Supplement for a period of one hundred twenty (120) days from its Effective Date or the date of last reinstatement, whichever is
later; or
(10) circumcision; or
(11) any nervous or mental disorder; or
(12) disease or infection with any human immunodeficiency virus (HIV) and/or any HIV-related illness including Acquired Immune Deficiency Syndrome
(AIDS) and/or any mutations, derivations or variations thereof; or
(13) any attempt or commission of assault or unlawful act by the Insured; or
(14) any act of war, declared or not, or while in military, naval or air service for any country at war, declared or not; or
(15) any Confinement for treatment, procedure or other medical services which are not Medically Necessary.

*Pre-existing condition means a condition (a) for which the Insured received medical advice, consultation or treatment, or (b) whose signs or symptoms are
evident, or should have been evident to the Insured, even if the Insured did not seek medical advice, consultation or treatment during the two years preceding
the supplement effective date, or reinstatement date, whichever date is later. “Condition” means any type of illness, specific injury, disease or infirmity
including all underlying or related conditions and any manifestation thereof, whether in one or more than one body system.

Cooling-off Period: You may return or cancel the supplement contract within 15 days from the date you received the contract. You will receive a full refund of

Page 14 of 18 of Proposal No. 32886-202008150714-3-02 Policy No: 3114924214

Printed on: 2/4/2021 05:03:37 PM Created on: 08/15/2020 Expiry Date: 10/14/2020
Version Number: 6.0.0 Date for Next Insurance Age: 04/15/2021
Plan Code: TR05/ Rider Code: MEB2
FlexiProtect Philippine Peso
for: LORADEL MACABIDANG TURCULAS, Female, 44, Non-smoker
your Premium. No refund can be made when you have already made a claim on your supplement.

Page 15 of 18 of Proposal No. 32886-202008150714-3-02 Policy No: 3114924214

Printed on: 2/4/2021 05:03:37 PM Created on: 08/15/2020 Expiry Date: 10/14/2020
Version Number: 6.0.0 Date for Next Insurance Age: 04/15/2021
Plan Code: TR05/ Rider Code: MEB2
FlexiProtect Philippine Peso
for: LORADEL MACABIDANG TURCULAS, Female, 44, Non-smoker
NOTES:
1. The rates shown, if any, are those currently in effect. The rates applicable upon renewal of the Supplement will be those in effect at the date of
renewal.
2. For a detailed description of the Supplements, including exclusions and other provisions, please refer to the policy contract.

Page 16 of 18 of Proposal No. 32886-202008150714-3-02 Policy No: 3114924214

Printed on: 2/4/2021 05:03:37 PM Created on: 08/15/2020 Expiry Date: 10/14/2020
Version Number: 6.0.0 Date for Next Insurance Age: 04/15/2021
Plan Code: TR05/ Rider Code: MEB2
 Reference Number: 32886-202008150714-3-02

FINANCIAL UNDERSTANDING SUMMARY

Dear LORADEL

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 40,000.00, and after taking into consideration your objectives, risk
profile and priorities, you have selected FlexiProtect 5 Life (RP) for your Income Protection
need.

The details of your insurance coverage and your insurance premium are summarized in your
FlexiProtect 5 Life (RP) sales illustration.

DE VERA, JOYLIN PAULA MENDOZA

43237
32886
639175055194

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: 3114924214

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: 3114924214

Proposal/Illustration of Benefits: 3114924214

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

LORADEL TURCULAS
Name and Signature of Proposed Insured

Signed in the Philippines

Date of Signing:

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