Reference Number: ___________

Client’s Declaration Form

I have actually read and understood the full text of the
Declarations, Agreements and Acknowledgement of the Forms
before signing them:

Application Form: ___________________________

Proposal/Illustration of Benefits: ___________________________

Investment Portfolio Risk Assessment Form: ___________________________

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

______________________________ Name and Signature of Policy Insured

Name and signature of Policy Owner (If age 18 and above)

Signed on: __________________________

Signed at: __________________________

_______________________________