CLIENT'S INFORMATION SHEET

PROPOSED OWNER
Last name First name Middle Name

Date of Birth (dd/mm/yyyy)

Place of Birth Nationality

Civil Status Sex Height Weight

Smoker? No if Yes please specify no.of Sticks per day

Occupation Nature of Business Monthly Income

Type of Government Issued ID:

Government ID #:

Residence Address:

Zip code

Company Name/Business Address:

Zip code
CONTACT NUMBER (Pls. provide at least two)
Home Phone no.
Mobile Number
Business Phone no.
E-mail Address
Source of Funds/Monthly Income :
Mode of Payment (annual, semi annual, quarterly, monthly):
Payment method: (cash, credit card, automatic debit on savings account):
 BENEFIC

Name (Last Name, First Name, Middle Nam Present Address

 BENEFICIARIES

Place of Birth Date of Birth occupation Relationship Contact Number Benefit (Total
(mm/dd/yyyy) of 100%)
 Irrevocable - an
Primary - first to approval from the
claim the beneficiaries is
benefits/Secondary required to make any
- will be able to
claim the benefits changes on the
when primary plan /Revocable- the
beneficiaries have insured or policy
passed on owner has the full
control on the plan.
 DECLARATION OF PROPOSED INSURED

2
3
4
5
6
7

4
5

1
 DECLARATION OF PROPOSED INSURED

Have you ever had an application for Life, Critical Illness, Medical or Disability instrument that was:
a. modified, rated or offered with reduced face amount, declined or postponed?
b. rejected for reinstatement or renewal due to healthy medical measures?
Have you ever made a claim for Accident, Medical Care, Critical Illness or other benefits?
Have you ever made a disability claim or are you presently receiving a disability benefit?
Are you presently incacpable for work?
Do you participate or intent to participate in any hazardoius activities related yo your occuptaiton or any recreational activities
mountaineering or climbing, skydiving, parachuting, hang-gliding, motor sports or aviation (excluding flying as passenger on a
Have you ever taken any habit forming drugs or narcotics or been treated or counselled for a drug problem?
Do you consume alcoholic beverages? If yes, give the type and number of drinks per day and/or per week

Have you ever smoked or use nay of the following in the last twelve months?:
a. cigarettes
b. e-cigarettes
c. vape
d. smokeless tobacco
e. never smoked

Have you experienced any weight change in the last 12 months? If yes, please state amount gained or lost (kg) and the reason
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 or any heart/blood/vascular diseases.
b. cancer (including melanoma, tumor or growth of any kind)
c. Diabetis, thyroid disease, metabolic or endocrine diseases.
d. Hepatitis B or C (including hepatitis carrier), HIV infection. Liver, gallbladder, or any gastrointestinal diseases.
e. Kidney diseases, diseases of the genitourinary system, breast diseases, or any reproductive organ diseases.
f. any musculoskeletal diseases (including joint/bone diseases, arthritis) or any auto-immune diseases (including lupus).
g. Eyes/ears/nose/throat diseases or any respiratory diseases.
h. Epilepsy, head/brain injury, paralysis, psychiatric diseases or other neurological diseases.
In the last 5 years, have you been diagnoses, tested positive or received medical treatment or been prescribed medication for
(other than for minor conditions such as cold or flu)?
Are you currently receiving any medical treatment or intend seeking or have been advised by a physician to seek medical treat
results of any medical tests/investigations?
Have your biological mother, father, brother(s) or sister (s) been diagnosed, before age 60, with any of the following: cancer, h
FOR FEMAL APPLICANT O
Are you currently pregnant?
 Kindly answer YES or NOIf YES, please indicate details

# of sticks per day/ # of

packets per day/# of
months or years

her inherited conditions?