Policy Number

311 - 8131717

Application for Health Start Application Number R 999989-202412130317-7-02

(Simplified Issue Offer) Multiple Application 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.

Important Notes: FOR OFFICE USE ONLY

1. An Insurance is a contract of utmost good faith and the Proposed Date Received:
Insured/Proposed Owner is required to disclose ALL material facts to the
insurer. All answers to the questions stipulated in this questionnaire are the Time Received:
basis of and are an inseparable part of the insurance policy. In case of doubt Receiving
as to whether a fact is material or not, the fact should be disclosed. Dept./Office:
2. Please do not sign on a blank form.
3. Please shade the circle to indicate your choice(s).
1. DETAILS OF PROPOSED INSURED, CO-INSURED AND POLICY OWNER
Proposed Policy Owner
Single Life Plan Proposed Principal Insured (For Single Life Plan, please complete this section if different from Notes
Proposed Principal Insured)

Proposed Principal Insured

Joint Life Plan (For Joint Life Plan, Policy Owner is same as Principal
Proposed Co-Insured Politically Exposed Person (PEP)

Insured) is an individual who is or has

been entrusted with
FULL NAME prominent public positions in
( Last Name, First Name, YEAH TERPZ TESTING the Philippines with
Middle Name) substantial authority over
policy, operations, or the use
RELATIONSHIP TO PRINCIPAL or allocation of government-
INSURED Spouse Parent Sibling Child owned resources; or a foreign
state or international
DATE OF BIRTH (yyyy, mm, dd) 1980/01/01 organization, including heads
of state or of government,
PLACE OF BIRTH TESTING senior politicians, senior
national, or local
SEX government, judicial or
Male Female Male Female
military officials, senior
executives of government or
CIVIL STATUS Single Married Widow Divorced/Annulled Single Married Widow Divorced/Annulled
state-owned or controlled
NATURE OF OCCUPATION / corporations and important
A political party officials.
BUSINESS
SPECIFIC OCCUPATION Accountant The requirements for all types
of PEPs also apply to (1)
IF WORKING ABROAD, immediate family members of
UNITED ARAB EMIRATES (UAE) - DUBAI PEPs, which refer to
STATE THE CITY/PROVINCE AND COUNTRY
individuals related to the PEP
within the second degree of
IDENTITY NUMBER
SSS: 1111111111 consanguinity and afinity
(TIN, SSS OR GSIS) and (2) close
relationship/associates of
NATIONALITY Philippines PEPs which refers to persons
who are widely and publicly
RESIDENCE/PRESENT known, socially or
ADDRESS 111 11 11 11 1012 professionally, to maintain a
( No. , Street, City, Province, Zip Code) particularly close relationship
with the PEP and include
PERMANENT ADDRESS persons who are in a position
111 11 11 11 1012 to conduct substantial
( No. , Street, City, Province, Zip Code)
domestic and international
BUSINESS NAME / financial transactions on
TESTING
NAME OF EMPLOYER behalf of the PEP.

BUSINESS ADDRESS 111 11 11 11 1012

PREFERRED MAILING ADDRESS Residence Permanent Address Business Residence Permanent Address Business Residence Address should be
(Select One) a Philippine Address (in
reference to Cross-Border
HOME PHONE HOME PHONE Rule)
CONTACT INFORMATION
BUSINESS PHONE BUSINESS PHONE Residence Address shall be
used as default mailing
MOBILE 639999999999 MOBILE address

E-MAIL (Mandatory) [email protected] E-MAIL (Mandatory)

Unless you are a bank
SOURCE OF FUNDS/ employee, Bank address
Salary / 10000000.00
MONTHLY INCOME and contact information
should not be used
ARE YOU A US CITIZEN YES NO YES NO
OR US TAX RESIDENT? US TIN/SSN : US TIN/SSN :
YES NO YES NO
ARE YOU AND/OR IMMEDIATE
FAMILY MEMBER A POLITICALLY If yes, please specify government position/public office If yes, please specify government position/public office
EXPOSED PERSON (PEP)?
BENEFICIAL OWNER (if any)
(Full name, Present address, Date and
place of birth, Nature of work, Sources of funds)

PATSXXEXSIO-0419 1/22
Application for Health Start Application Number R 999989-202412130317-7-02

2. DETAILS OF THE COMPANY (IF OWNER IS THE COMPANY)

FULL BUSINESS/COMPANY NAME FULL NAME OF AUTHORIZED SIGNATORY

Notes

NATURE OF BUSINESS FULL NAME OF AUTHORIZED SIGNATORY

Only applicable for single life

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

CONTACT INFORMATION OF AUTHORIZED SIGNATORY
Definition of beneficial
MOBILE NUMBER (Mandatory) BUSINESS ADDRESS owner per 2018 IRR of RA
9160, otherwise known as
the AML Act of 2001, as
amended.
BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory) “(l) “Beneficial Owner” refers
to any natural person who:
(1) Ultimately owns or
controls the customer and/or
SOURCE OF FUNDS on whose behalf a
transaction or activity is
being conducted; (2) Has
ultimate effective control
over a juridical person or
legal arrangement; or (3)
3. BENEFICIARY DESIGNATION Owns, at least, twenty
percent (20%) shares,
contributions or
Proposed Principal Insured equity interest in a juridical
person or legal
arrangement. Control
Name . *Type of Beneficiary Irrevocable includes whether the control
Sex / Date of Birth/ Benefit
(Last, First, Middle Name)/ Nationality Relationship to (optional) (Please shade if is exerted by means of trusts,
Gender Place of Birth Nature of Work % Irrevocable
Present Address/Contact No. Proposed Insured Beneficiary) agreements, arrangements,
Primary Secondary
understandings, or practices,
TERPZ2, TESTING TESTING and whether or not the
2006/09/18
TESTING TESTING TESTING TESTING Male Philippines Accountant Sibling 100
639999999
A individual can exercise
control through making
decisions about financial and
Proposed Co Insured (For Joint Life Only) operating policies.”

Name Sex / . Date of Birth/ Benefit *Type of Beneficiary Irrevocable

(Last, First, Middle Name)/ Nationality Relationship to (optional) (Please shade if
Gender Place of Birth Nature of Work % Irrevocable
Present Address/Contact No. Co - Insured Beneficiary)
Designation of a minor as
Primary Secondary
Irrevocable beneficiary is
discouraged.

Secondary Beneficiaries are

entitled to the benefits if no
Primary Beneficiary
survives.
4. BASIC PLAN DETAILS When policy owner (PO)
designates a revocable
beneficiary, the PO may
PLAN NAME BASIC SUM INSURED change the policy details,
PAYMENT TERM including its beneficiaries,
Health Start 10-Pay 1,000,000.00 10-Pay 20-Pay any time. However, when PO
designates irrevocable
beneficiary, PO may not
change the details of the
PURPOSE OF THE INSURANCE APPLIED FOR: policy, without prior consent
of said irrevocable
Health protection Fringe Benefit or Keyman beneficiary.

Selection of “Waiver of
Premium” as policy
supplement applies to the
5. PAYMENT INSTRUCTIONS basic and supplement riders
where it is applicable

MODE OF PAYMENT METHOD OF PAYMENT Billing cycle: policies with 1-

15 as Effective Date shall be
Annual Semi-annual Auto-Debit Arrangement (ADA) Credit Card Cash charged every 5th of the
month while those with 16-28
Quarterly Monthly Post Dated Check (PDC) Initial premium Recurring Others: as Effective Date shall be
charged every 20th of the
month. For rejected billings
due to insufficient balance, we
will initiate rebilling efforts in
6. PREMIUM DEFAULT OPTIONS an objective to keep your
policy in-force.

Requests for cancellation of

ADA/CC payments should be
* PREMIUM PAYMENT DEFAULT OPTION submitted 30 days prior to
Extended term insurance (ETI) the scheduled debit/ charge
date.
Automatic Premium Loan (APL)
Requests for PDC pull-out
* By default, if no Premium Option is selected, ETI will apply should be received at least 5
working days before the
check maturity date.

PATSXXEXSIO-0419 2/22
Application for Health Start Application Number R 999989-202412130317-7-02

7. DECLARATION OF PROPOSED PRINCIPAL INSURED and CO-INSURED

Principal Insured Principal Co-Insured
Questions If yes, please provide details
Smoker Non-Smoker Smoker Non-Smoker
1. Have you ever had or received medical advice or treatment
or medication for any of the following?
(a) Chest pain, high blood pressure, heart attack, stroke,
diabetes, kidney disease, liver disease, elevated
cholesterol or any heart/blood/vascular disorder, AIDS or Yes No Yes No
infection with HIV?
(b) Cancer, mass, tumor, lump / polyp / cyst / growth of any
kind?
2. Are you currently intending to seek or have been advised to
seek medical treatment or take medication for any health Yes No Yes No
problem (other than for common cold) or are you waiting for
the results of any test or investigation?
3. Has your biological mother, father, or any sister or brother
been diagnosed prior to the age of 60 with any of the
following?
(a) Cancer; or Yes No Yes No
(b) Heart Attack; or
(c) Stroke?
4. Height 5'1"(ft. & in.) or 154(cm.) and weight 123lbs. or
55.7919kg.
Yes No Yes No
a.Have you experienced any weight change in the last 12
months? If yes, please state amount gained or lost (kg) and the
reason for weight change.

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

activities related to your occupation or any recreational Yes No
Yes No
activities such as (but not 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)?

6.8.
HasREPLACEMENT OF EXISTING
your child or any of your children LIFE INSURANCE POLICIES
been diagnosed or
undergone treatment for, or been suspected by the doctor of
having any of the following?
Replacing A
(a) Hemophilia anand/or
existing life insurance
Hemophilia B with a new one is in most cases disadvantageous as you might be confronted with a loss of financial
(b) Insulin
benefitsDependent
or higherDiabetes
premiumsMellitus
in the new plan. Before you decide to replace a policy, ensure that you have full information of both policies.
(c) Osteogenesis Imperfecta Yes No Yes No
(d) Wilson’s Disease
Is this Policy
(e) Kawasaki Diseasereplacing another policy with AXA or any other insurance company? Yes No
(f) Rheumatic Fever

** Children diagnosed with, undergoing treatment or under suspicion of critical illnesses listed in question 6 prior to the effectivity of the policy are not covered.

9. 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/We have read and understood all declarations and agreements which are hereby given and made willingly and voluntarily and with full
knowledge of my/our 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 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/our 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/our application/policy;
b. to provide all services related to my/our 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/us 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.

PATSXXEXSIO-0419 3/22
Application for Health Start Application Number R 999989-202412130317-7-02

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/We understand that notices related to my/our policy may be sent to me/us through mail, email, or SMS in the mailing/email address/number I/we
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. 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 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 5, is actually paid during the lifetime and good
health of the Proposed Insured/s.

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 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)

17. I/We understand that I/we have the right to cancel the policy to be issued during the cooling-off period provided therein and obtain a full refund 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.

10. 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

PATSXXEXSIO-0419 4/22
Application for Health Start Application Number R 999989-202412130317-7-02

11. 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.

**PLEASE DO NOT SIGN ON A BLANK FORM

Date of Signing: Place of Signing:

TERPZ YEAH
Signature (Proposed Principal Insured) Signature (Proposed Co-Insured / Proposed Owner for single life)

**(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.

PATSXXEXSIO-0419 5/22
Application for Health Start Application Number R 999989-202412130317-7-02

Name of Advisor/FE: TEST ACCOUNT, TEST TEST Name of Advisor/FE:

Code: Code:

99999 4 999989

Signature: Signature:

12. 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: TEST ACCOUNT, TEST TEST Name of Advisor/FE

Signature: Signature:

PATSXXEXSIO-0419 6/22
Application for Health Start Application Number R 999989-202412130317-7-02

Application Number R 999989-202412130317-7-02

TEMPORARY LIFE INSURANCE CERTIFICATE

There is temporary insurance on the life to be insured beginning on the date of signing by Proposed Principal Insured, Proposed Co-Insured or the Proposed Policy
Owner, if applicable 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 1-5 stated on section no. 7 were answered “NO” and (3.) All other required
questions in the Application form are answered completely and truthfully. All conditions under this certificate are subject to the Provisions of the Policy the Proposed
Principal Insured, Proposed Co-Insured or Proposed Policy Owner, if applicable 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, 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 Insured. The maximum amount of PhP1,000,000 includes any accidental death benefit, under all Temporary Life Insurance Certificates
inforce in respect of the Insured. However, if the insurance benefit paid for by the 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 Insured. For Joint plan, this can be claimed once only, on a first-to-claim basis.
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/s;
(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/s;
(d) The date of death of the Proposed Principal Insured or Proposed Co-Insured, if applicable; 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.

PATSXXEXSIO-0419 7/22
Application for Health Start Application Number R 999989-202412130317-7-02

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.

PATSXXEXSIO-0419 8/22
Health Start Proposed Insured:
Mr. TERPZ TESTING YEAH
Age 45, Male, Non-smoker

Policyowner:
Mr. TERPZ TESTING YEAH
Age 45, Male

Dear TERPZ,

Congratulations! You’ve chosen the right partner to help you have a head-start in protecting your health. AXA
Philippines is a formidable synergy between two financial giants - the AXA Group and the Metrobank Group.

We are happy to share with you the details of your chosen health plan, Health Start . Below is a summary of your
plan and the benefits you can enjoy.
Sum Insured Php 1,000,000
SUMMARY OF BENEFITS
Major Critical Minor Critical Return of Life Insurance Child Cover
Conditions Conditions Premium Coverage Benefit

Receive Receive 20% of the At Age 75, receive In case of the Receive
Php1,000,000 in Sum Insured in a lump-sum insured’s untimely Php200,000 in
case the insured case the insured equivalent to the demise, your loved case your child, if
encounters: encounters any of total premiums you ones will receive any, gets
• Cancer the 9 Minor Critical have paid Php1,000,000 to diagnosed with any
• Stroke Illness Conditions help in taking care of the Child Critical
• Heart of their needs Conditions
Attack
• Terminal
Illness

Notes:
1. The policy terminates after claiming either of the Major Critical Conditions or the Life Insurance Coverage. Life Insurance
Coverage is interchangeably used as death benefit in this proposal, pertains to one and the same benefit.
2. Minor Critical Conditions can be claimed for a maximum of four (4) times throughout the lifetime of the policy and
should be for different conditions, except for carcinoma-in-situ of different organs. The amount of benefit paid or payable
will be deducted from the Major Critical Conditions Benefit and Death Benefit payable under the Basic Plan. Please
refer to the conditions stated on the subsequent pages for the covered illnesses.
3. Return of premium will be LESS any minor critical illness benefit paid and any indebtedness. In case of substandard
rating, return of premium will follow the standard premiums only. For issue age up to 54, this is equivalent to 100% of
total standard premiums paid. For issue age 55 and up, this is equivalent to 50% of total standard premiums paid.
4. Life Insurance Coverage will be LESS any minor critical illness benefits paid, any Return of Premium paid and any
indebtedness.
5. The Child Cover Benefit is provided for any one child who is under 18 years old at the time of claim or first diagnosis.
This benefit is payable only once, on a first child-to-claim basis. Child Cover Benefit is on top of the plan’s sum insured.
6. Major, Minor Critical Conditions and Child Cover Benefit are payable according to the illness definitions as set out in the
policy contract.

Page 9 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:48 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

You may also boost your plan by adding optional supplements which can provide the following benefits:
• WAIVER OF PREMIUM ensures your policy’s future basic premiums will be paid for in case you become
totally and permanently disabled before age 55.

Enjoy these benefits or supplements for a minimal additional Annual Premium of Php 2,040.00 payable for 10 years.

The succeeding pages of this proposal provide more details on the benefits and features of Health Start.

Again, thank you for your interest in our products. If you have questions, please call me at the number specified
below or call the AXA Customer Care Hotline at +632 5815-292.

TEST ACCOUNT, TEST TEST

99999
999989
639267794236

Page 10 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:48 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

PREMIUM DETAILS
Plan/Supplements Cover up Sum Insured / Annual Premium
to Age* Coverage (PHP) (PHP)
HEALTH START 10-PAY 100 1,000,000 58,220.00
WAIVER OF PREMIUM** 60 - 2,040.00

Total Initial Annual Premium 60,260.00

Semi-Annual Premium 31,335.20
Quarterly Premium 16,270.20
Monthly Premium 5,724.70

*Cover up to Age refers to Termination Age.

** Covers basic plan premium

Notes:
The premium rates for Health Start are not guaranteed and the Company reserves the right to review and adjust the premium
rates from time to time. We will communicate any change in premium rates by mail or in any other applicable form.

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 11 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:48 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

ILLUSTRATION OF BENEFITS

Death Benefit /
End of Guaranteed Return of
Attained Age Total Living Benefit Major Critical
Year Cash Value Premium
Conditions Benefit

1 46 0 0 0 1,000,000
2 47 15,589 0 15,589 1,000,000
3 48 45,730 0 45,730 1,000,000
4 49 90,643 0 90,643 1,000,000
5 50 137,745 0 137,745 1,000,000
6 51 186,687 0 186,687 1,000,000
7 52 237,524 0 237,524 1,000,000
8 53 290,381 0 290,381 1,000,000
9 54 336,297 0 336,297 1,000,000
10 55 382,111 0 382,111 1,000,000
15 60 444,651 0 444,651 1,000,000
20 65 510,950 0 510,950 1,000,000
25 70 583,673 0 583,673 1,000,000
30 75 204,432 582,200 786,632 417,800
35 80 225,005 0 225,005 417,800
40 85 244,634 0 244,634 417,800
45 90 267,957 0 267,957 417,800
50 95 295,315 0 295,315 417,800
55 100 332,925 0 332,925 417,800

Notes:

1. The Guaranteed Cash Value refers to the amount paid to the Owner upon termination of the policy prior to death. Any Minor Critical
Conditions benefit claims paid are deductible from the Guaranteed Cash Value. At any time, the total Minor Critical Conditions benefit
paid is higher than the Guaranteed Cash Value, the surrender amount is reduced to zero.
2. The Return of Premium refers to the cash endowment paid on the Policy Anniversary nearest the 75th birthday of the insured. For issue
age up to 54, this is equivalent to 100% of total standard premiums paid. For issue age 55 and up, this is equivalent to 50% of total
standard premiums paid. Illustration assumes that there were no minor condition claims made or any outstanding loans.
3. The Total Living Benefit refers to the sum of the Guaranteed Cash Value, and the Return of Premium (if any) payable to the Owner if
he/she decides to surrender/terminate the plan. The Return of Premium is illustrated as paid out at age 75.
4. The Death Benefit or the Major Critical Conditions Benefit is (1) the sum insured payable upon the demise of the insured or diagnosed
of any of the covered Major Critical Conditions less (2) any Minor Critical Conditions Benefits paid, any cash endowment paid, and any
Indebtedness.
5. The Minor Critical Conditions Benefit can be claimed for a maximum of 4 times throughout the lifetime of the policy and should be for
different conditions, except for carcinoma-in-situ of different organs. The amount of benefit paid or payable will be deducted from the
Major Critical Conditions Benefit, Death Benefit, Guaranteed Cash Value or Return of Premium payable under the Basic Plan.
6. All amounts are in the currency indicated in the Summary of Benefits page.
7. This proposal is only an illustration of the key features, benefits and assumptions of the recommended insurance plan. For the
complete terms, conditions and limitations of the plan please refer to your policy contract.

Page 12 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:48 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

CONDITIONS COVERED
Major Critical Conditions
Cancer
Heart Attack
Stroke
Terminal Illness

Minor Critical Conditions

Conditions related to Cancer 1. Carcinoma-in-situ at Breast, Uterus, Fallopian
Tube, Vagina, Cervix Uteri, Testicles, Ovary, Colon,
Rectum, Penis, Lung, Stomach or Vulva
2. Early stage prostate cancer
3. Early Bladder Cancer
4. Early Chronic Lymphocytic Leukemia
Conditions related to the Heart 5. Angioplasty and Other Invasive Treatments for
Coronary Artery Disease
6. Aortic Aneurysm
7. Insertion of Pacemaker or Defibrillator
8. Keyhole Coronary Bypass Surgery
Conditions related to the Nervous System 9. Cerebral shunt insertion

Critical Conditions under the Child Cover Benefit

1. Dengue Hemorrhagic Fever (Grades III and IV)
2. Hemophilia A or Hemophilia B
3. Insulin Dependent Diabetes Mellitus
4. Kawasaki Disease
5. Osteogenesis Imperfecta
6. Rheumatic Fever with Valvular Impairment
7. Still’s Disease
8. Wilson’s Disease

Notes :
1. Any child of the Insured may receive a Child Cover Benefit provided that the child is under eighteen (18) years old at the time of first
diagnosis of the covered Child Critical Condition. This benefit is payable once only, on a first child-to-claim basis.

2. The critical condition must occur 60 days after the policy’s effective date for the corresponding Major Critical Condition Benefit,
Minor Critical Condition Benefit or Child Cover Benefit to be payable. These benefits are payable according to the illness definitions as
set out in the policy contract.

Page 13 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:48 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

MAJOR CRITICAL CONDITIONS

No. ILLNESS NAME DEFINITION
1. Cancer The first unequivocal diagnosis of any malignant tumor characterized by the
uncontrolled growth of malignant cells and invasion of tissue, and positively diagnosed
with histological confirmation by a specialist and/or by Our medical director or
authorized medical consultant. The term malignant tumor includes leukemia, sarcoma
and lymphoma except cutaneous lymphoma (lymphoma confined to the skin).

Breast carcinoma in situ with subsequent radical mastectomy and radiotherapy is

covered.

For the definition shown above, the following are excluded:

1. All tumors which are histologically classified as benign, carcinoma in situ, pre-
malignant, non-invasive, having borderline malignancy or having low
malignant potential;
2. Tumors treated by endoscopic procedures alone and urinary bladder tumors
that have not Invaded the muscle layer (Tis and Ta)
3. Tumors of the skin with the exception of malignant melanoma greater than
0.7 mm Breslow and/or histologically described by the AJCC seventh edition
TNM classification greater than stage T1aN0M0
4. All prostate tumors unless histologically classified as having a Gleason score
greater than 6 or having progressed to at least clinical TNM classification
T2N0M0
5. Thyroid tumor in its early stages that measures less than 2cm in diameter
and histologically described as T1N0M0 from TNM classification of the AJCC
Seventh Edition
6. Chronic lymphotic leukemia unless histologically classified as having
progressed to at least Binet Stage A

2. Heart Attack Death of heart muscle due to inadequate blood supply that has resulted in ALL of the
following evidence of acute myocardial infraction:

· New typical ischemic changes in the electrocardiograph:new ST-T changes or

new left bundle branch block or new pathological Q waves;
· The characteristic rise of cardiac biomarkers or Troponins recorded at the
following levels or higher:
Troponin T > 200ng/L (0.2 ng/ml or 0.2 ug/L)
AccuTnl > 500ng/L (0.5 ng/ml or 0.5 ug/L)

The following are excluded:

· Other acute coronary syndromes

· Angina without myocardial infraction

Page 14 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:49 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

3. Stroke Stroke means the death of brain tissue caused by hemorrhage, embolism or
thrombosis resulting in permanent neurological deficit with persistent clinical
symptoms. There must be clear and obvious abnormalities of sensory or motor
functions during the physical examination performed by a neurologist and/or by Our
medical director or authorized medical consultant. The incident must be demonstrated
by Magnetic Resonance Imaging (MRI), Computerized Tomography (CT) or other
reliable imaging techniques approved by the Company.

The following are excluded:

· Transient ischemic attack
· Brain tissue damage caused by head injury
Death of tissue of the optic nerve or retina / eye stroke
4. Terminal Illness The life Insured must be suffering from a condition, which in the opinion of a specialist
and/or by Our medical director or authorized medical consultant, according to Our
guidelines, will lead to death within twelve (12) months.

Page 15 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:49 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

MINOR CRITICAL CONDITIONS

No. ILLNESS NAME DEFINITION
1. Carcinoma-in-situ Carcinoma-in-situ is defined as a focal autonomous new group of carcinomatous cells
which has not yet resulted in the invasion of normal tissue. Invasion means an
infiltration and/or active destruction of normal tissue beyond the basement
membrane. Diagnosis of carcinoma-in-situ must be supported by a histopathological
report and a positive result of a microscopic examination of fixed tissue, and confirmed
by a biopsy result. Clinical diagnosis does not meet this standard.

For the purpose of this policy, carcinoma-in-situ is limited only to the following 13
organs:
(1) Cervix Uteri* (8) Colon
(2) Uterus (9) Lung
(3) Breast (10) Penis
(4) Vagina (11) Rectum
(5) Fallopian Tube (12) Stomach
(6) Ovary** (13) Vulva
(7) Testicles

*For carcinoma-in-situ of cervix uteri, it must be at a grading of not less than CIN III and
be positively diagnosed upon the basis of a microscopic examination of fixed tissue
from a cone biopsy or colposcopy with cervical biopsy.
**For carcinoma-in-situ of ovary, the tumors should be capsule intact, with no tumor
on the ovarian surface, classified as T1aN0M0, T1bN0M0 (TMN classification) or FIGO
1A, FIGO 1B (The Federation Internationale de Gynecologie et d’Obstetrique).

In order to qualify for a benefit under this illness for the second time, the Carcinoma-in-
situ of the second claim must be a Carcinoma-in-situ of the organs that is different
from the organ of the first claim for which benefit has been paid.

For the avoidance of doubt, for those organs with both left and right component
(including but not limited to breast, ear, eye, fallopian tube, kidney, lung, ovary and
testicle), the left component and right component of the organ shall be considered as
one and the same organ.
2. Early Stage Cancer of A prostate malignant tumor which is histologically classified as T1a, T1b, T1c according
Prostate to the TNM classification system or another equivalent classification, and having a
Gleason score below 7. The diagnosis must be based on histopathological features
and confirmed by a Specialist. Pre-malignant lesions and conditions, unless listed
above, are excluded.
3. Early Stage of Urinary/ Bladder cancer which is histologically described using TNM classification as T1N0M0
Bladder Cancer as well as Papillary micro-carcinoma of Bladder. Diagnosis must be supported by
histopathology report.
4. Early Stage of Chronic Chronic Lymphocytic Leukemia (CLL) RAI Stage 1 or 2. RAI stage CLL 0 or lower is
Lymphocytic Leukemia excluded.
5. Insertion of Pacemaker The undergoing of insertion of a permanent cardiac pacemaker or a cardiac
or Defibrillator defibrillator to correct serious cardiac arrhythmia which cannot be treated via other
methods. The insertion of the cardiac pacemaker or cardiac defibrillator must be
certified to be medically necessary by a specialist in cardiology and/or by Our medical
director or authorized medical consultant, according to Our guidelines.

Page 16 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:49 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

6 Angioplasty and Other The actual undergoing of balloon angioplasty, atherectomy or laser treatment to
Invasive Treatments for correct narrowing in major coronary arteries (defined as being greater than 50%
Coronary Artery Disease stenosis in 2 or more major coronary arteries; or being greater than 75% stenosis in 1
or more major coronary artery by angiogram). The treatment must be considered
medically necessary by a specialist and/or by Our medical director or authorized
medical consultant, according to Our guidelines, either to relieve exercise limiting
symptomatology which is not responding adequately to medical therapy or in order to
achieve a prognostic benefit. For purposes of this definition, “major coronary artery”
refers to any of the left main stem artery, left anterior descending artery, circumflex
artery and right coronary artery (but not including their branches).

In order to qualify for a benefit under this illness, there must be:

(1) History of symptoms which are sufficiently severe to indicate that the Life Insured’s
future level of exercise tolerance would be restricted, despite medications, to a
minimal level without percutaneous intervention; and
(2) Medical evidence including all of the following:
2.1 Report from attending specialist; and
2.2 Evidence of significant and relevant ECG changes (ST segment depression of 2
millimeters or more); and
2.3 Angiographic evidence to confirm the location and degree of stenosis in major
coronary artery.
7. Aortic Aneurysm The diagnosis of a large abdominal or thoracic aortic aneurysm as evidenced by
appropriate imaging technique. The aorta must be enlarged greater than 50 mm in
diameter and the diagnosis must be confirmed by a specialist in cardiology and/or by
Our medical director or authorized medical consultant, according to Our guidelines. For
this definition, aorta means the thoracic and abdominal aorta but not its branches.
8. Keyhole Coronary The undergoing for the first time for the correction of the narrowing or blockage of one
Bypass Surgery or more coronary arteries with bypass grafts via "Keyhole" surgery. The surgery must be
considered medically necessary by a Specialist. All intra-arterial catheter-based
techniques are excluded from this benefit.
9 Cerebral Shunt Insertion The actual undergoing of surgical implantation of a shunt from the ventricles of the
brain to relieve raised pressure in the cerebrospinal fluid. The need of a shunt must be
certified to be medically necessary by a specialist in neurology.

Page 17 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:49 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

CHILDREN COVER BENEFIT CRITICAL CONDITIONS

No. ILLNESS NAME DEFINITION
1. Dengue This severe grade of dengue is characterized by circulatory failure (Dengue Shock Syndrome
Haemorrhagic DSS - WHO DHF grades III and IV), in addition to the 3 symptoms below:
Fever (Grades
III and IV) 1) High fever;
2) Hemorrhagic phenomena;
3) Hepatomegaly.

The diagnosis of Dengue Hemorrhagic Fever must be confirmed by a specialist and/or by Our
medical director or authorized medical consultant, according to Our guidelines. Non-
Hemorrhagic Dengue Fever is excluded.
2. Hemophilia A The covered child or children must be suffering from severe hemophilia A (VIII deficiency) or
OR Hemophilia hemophilia B (IX deficiency) with factor VIII or factor IX activity levels less than one percent (1%).
B Diagnosis must be confirmed by a specialist and/or by Our medical director or authorized
medical consultant, according to Our guidelines.
3. Insulin Diabetes mellitus is chronic hyperglycemia, caused by defective insulin secretion. Insulin
Dependent Dependent Diabetes Mellitus is characterized by the continuous dependence on exogenous
Diabetes insulin for the preservation of life as diagnosed by a specialist and/or by Our medical director or
Mellitus authorized medical consultant, according to Our guidelines, and such dependence must persist
for at least 180 days.
4. Kawasaki This is acute, febrile and multisystem disease of children, characterized by non-suppurative
Disease with cervical lymphadenopathy, skin and mucous membrane lesions. Diagnosis must be confirmed
Heart by a specialist and/or by Our medical director or authorized medical consultant, according to
Complication Our guidelines, and there must be echocardiograph evidence or any other imaging test showing
cardiac involvement manifested by dilatation or aneurysm formation in the coronary arteries
which persists for at least 180 days after the initial acute episode.
5. Osteogenesis This is a genetic disorder characterized by brittle, osteoporotic, easily fractured bones. The
Imperfecta covered child or children must be diagnosed as a type III Osteogenesis Imperfecta confirmed by
the occurrence of all of the following conditions:

1) The result of physical examination of the covered child or children by a Doctor that the
covered child or children suffers from growth retardation and hearing impairment; and
2) The result of X-ray studies reveals multiple fracture of bones and progressive
kyphoscoliosis; and
3) Positive result of skin biopsy.

Diagnosis of Osteogenesis Imperfecta must be confirmed by specialist and/or by Our medical

director or authorized medical consultant, according to Our guidelines.
6. Rheumatic A confirmed diagnosis by a specialist and/or by Our medical director or authorized medical
Fever with consultant, according to Our guidelines, of acute rheumatic fever according to the revised Jones
Valvular criteria for its diagnosis. We only cover the case where there is involvement of one or more
Impairment heart valves and at least mild valve incompetence or stenosis attributable to rheumatic fever as
confirmed by quantitative investigations of the valve function by a qualified cardiologist
acceptable to Us.

Page 18 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:49 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

7. Still's Disease The occurrence of Still's Disease, a form of Juvenile Idiopathic Arthritis (JIL), where all
of the following conditions are met:

1)
There is widespread joint destruction as a result of the disease necessitating
hip or knee replacement; and
2) The diagnosis has been confirmed by a specialist and/or by Our medical
director or authorized medical consultant, according to Our guidelines.
8. Wilson's Disease A potentially fatal disorder of copper toxicity characterized by progressive liver disease
and/or neurologic deterioration due to copper deposit. The diagnosis must be
confirmed by a specialist and/or by Our medical director or authorized medical
consultant, according to Our guidelines, with liver biopsy and the treatment with a
chelating agent must be documented for at least 180 days.

Notes:
1. We will not pay the Major Critical Condition, Minor Critical Condition or the Child Cover Benefit under any of the
following:
a. The Insured is suffering from any Major or Minor Critical Conditions within sixty (60) days following the
Policy Effective Date or last reinstatement date of this Policy, whichever is later
b. For illnesses relating to congenital abnormalities
c. Any act of War (whether declared or not), invasion or acts of foreign enemies, civil war, revolution, rebellion,
civil commotion assuming the proportions of, or amounting to, an uprising against the government, riot or
insurrection, strike, or terrorist acts
d. Nuclear, biological or chemical (NBC) contamination
e. Any self-inflicted injury or suicide or any attempt thereat, whether sane or insane
f. Any unprescribed drug or alcohol abuse
g. Under Child Cover Benefit, we will not pay if the child is suffering from any covered child conditions within
sixty (60) days following the Policy Effective Date or last reinstatement date of this Policy, whichever is later
or the Child Critical Condition which resulted to death is within fourteen days from its diagnosis.
h. Pre-existing conditions as defined is permanently excluded

In case of Child Critical Condition Benefits, illnesses relating to congenital abnormalities are payable.

2. Pre-existing condition means a condition for which the Insured received medical advice, consultation or treatment,
or 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 for it prior to the Effective date of this Policy or date of effectivity of
its last reinstatement, if any. “Condition” means any type of illness, specific injury, disease or infirmity including all
underlying or related conditions and any manifestation thereof, whether in one (1) or more than one body system.

3. Cooling-off Period: You may return or cancel the contract within 15 days from the date you receive the contract. The
amount paid shall be returned in full to you.

Page 19 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:49 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
Health Start Philippine Peso
for: Mr. TERPZ TESTING YEAH, 45

Attached Supplements
Summary of the Riders Attached to this Proposal
1. WAIVER OF PREMIUM waives premium payments in the event you are suddenly unable to work and pay
for the premiums because of the disability. In effect, with a Waiver of Premium supplement, your policy will
be allowed to continue as if premiums are regularly and continuously paid.

The premium term of the supplement for waiver of premium is the same as the premium term of the plan
to which the supplement for waiver of premium is attached.

Notes:
1. The rates shown, if any, are those currently in effect. The rates may change subject to the approval of the Insurance Commission.
2. For a detailed description of the Supplements, including exclusions and other provisions, please refer to the policy contract.

DECLARATIONS AND ACKNOWLEDGEMENTS

Declarations
I confirm having read and understood the information contained in the Illustration of Benefits Page. My Financial
Advisor/Financial Executive fully explained to me the benefits, feature and, exclusions and limitations related to this
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. I
understand that the illustration(s) given to me are provided only to show how policy benefits would change over time
under a specific set of assumptions. In case of conflict between this Sales Illustration and the issued policy, the
latter shall prevail.
CONFORME: These declarations and acknowledgements are made with the
knowledge of AXA representative whose signature appears below:

Applicant/Policy Owner Date Financial Advisor/Financial Executive Date

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 20 of 22 of Proposal No. 999989-202412130317-7-02 Policy No: 311-8131717

Printed on: 12/13/2024 3:34:49 PM Created on: 12/13/2024 Expiry Date: 02/11/2025
Version Number: 6.2.0 Date for Next Insurance Age: 07/03/2025
Plan Code: SCI10 / Supplement code/s: WP
 Reference Number: 999989-202412130317-7-02

FINANCIAL UNDERSTANDING SUMMARY

Dear TERPZ,

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 100,000.00, and after taking into consideration your objectives,
risk profile and priorities, you have selected Health Start 10-Pay for your Health need.

The details of your insurance coverage and your insurance premium are summarized in your
Health Start 10-Pay sales illustration.

TEST ACCOUNT, TEST TEST

99999
999989
639267794236

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: 311-8131717

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: 311-8131717

Proposal/Illustration of Benefits: 311-8131717

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

TERPZ YEAH
Name and Signature of Proposed Principal
Insured
Signed in the Philippines - test
Date of Signing: 12-13-2024 03:24 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.