Reference Number

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

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 Proposed Insured Name and Signature of Proposed Co-Insured
(Applicable Only for Joint Life Plan)

Signed in the Philippines Signed in the Philippines

Date of Signing: Date of Signing:

Name and Signature of Proposed Owner

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.

UW-CDF 20191029 V2