APPLICATION FOR GROUP INSURANCE & STATEMENT OF HEALTH

Corporate Solutions

Name of Enrollee Date of Birth

Application for:
Employee/Member
Dependent
Last Name First Name Middle Name Month Day Year
Name of Employer or Group Group Policy No.

Total Amount of Insurance Involved Amount of Existing Insurance Additional Amount Applied For Height Weight
P P P

Please check  reason for LATE AMOUNT OVER

OVER AGE LIMIT REINSTATEMENT
submitting Health Statement ENROLLMENT SCHEDULED LIMIT

Please answer the following questions by checking the “Yes” or “No” box. Use this space or the reverse hereof to give full details of question 1 if
YES NO answered as "NO", or questions 2 to 4 if answered as “YES". Please
indicate question number/letter as reference. Give the date,
symptoms, diagnosis, duration, treatment, results, name of attending
1. Are you now actively at work or performing your physician, name and address of hospital/clinic. All statements
normal daily activities? contained herein and all attachments hereto are hereby made part of
2. Have you: this form.
a. Ever flown in an aircraft other than as a
fare-paying passenger?
b. Ever driven a motorcycle or engaged in
auto or motorboat racing, sky diving, scuba
diving, or other hazardous avocation?
c. Ever had any application for insurance or
reinstatement of insurance declined,
postponed or modified in amount, plan or
rate?
3. Have you:
a. Ever taken habit-forming drugs or
substances, alcoholic drinks to excess, or
had advice or treatment for such habit or
other addiction?
b. Ever had medical consultation or treatment
pertaining to:
i. brain or nervous system?
ii. lung or respiratory system?
iii. kidney or urinary system?
iv. heart or blood vessel?
v. stomach or other abdominal organs?
vi. reproductive organs or breast?
vii. diabetes, cancer, tumor or blood
diseases?
viii. AIDS, HIV (Human Immuno-
diffeciency Virus) infection or a
condition associated with either?
c. Ever had a positive blood test for AIDS or
HIV infection?
d. Ever had consultation, hospitalization or
surgical operation due to any condition not
mentioned above during the past 5 years?
e. Any mental impairment, physical defect,
tumor or lump or abnormal growth in any
part of the body?
f. Ever had during the past 2 years:
i. Loss of weight; dizzy spells; blood-
spitting; abnormality in breathing,
urination or bowel movement; or
unusual pain in any part of the body?
ii. Medical examinations, X-ray, ECG,
blood test or other diagnostic tests?
4. iii
ANSWER IF FEMALE:
a.
Have you ever had any unusual bleeding or
abnormality in menstruation, pregnancy or
childbirth?
b. Are you now pregnant? If so, how many
months?
I hereby declare and agree that all statements and answers contained herein and in any addendum annexed to this form, as well as those made to the
Medical Examiner (if applicable) contained in a written instrument signed by me and made part of this form, are full, complete and true and that this form
shall be part of my application to purchase additional insurance as stated above.

I further agree that the insurance coverage under this application is based on the truth of the foregoing declarations and representations and is subject
to the provisions of the Group Life Insurance issued by THE PHILIPPINE AMERICAN LIFE AND GENERAL INSURANCE COMPANY to
___________________________________________________________________________________________________________________________________________

(Company/Group)

IN CASE OF A MINOR DEPENDENT, I SIGN THIS CERTIFICATE

IN MY BEHALF AS PARENT AND IN BEHALF OF THE MINOR DEPENDENT

Date Signature of Dependent /Spouse Signature of Employee/Member

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February 2010 PHILAM LIFE CUSTOMER CONFIDENTIAL