Tree NON) [Please answer all the questions tn full and to the best of your knowledge. Ifyou are uncertain about whether the additional information you have is Inecessary to be declared. please declare anyway. It ean only help us determine if our produet will eater to your specif requirements. lease answer al the questions in ull and tothe best of your knowledge. Ifyou ere uncertain about whether the additional information you have is ‘necessary tobe declared, please declare anyway. It can only help us determine If our product wil eter to your specific requirements, Proposed _ | Family Member |Family Member] Family Member [Family Member] Family Member Principal insured 1 2 3 4 5 Prease write down in the space provided tne names of the persons to be insured according to the sequence in the previous pages. Has the person to.be insures a) ever nad a ite, health or erical iness application that was Oves ONo | Oves ONo | OYesONo |Oves ONo | Oves ONo | OvesONo ldecined, deterred, or accepted with higher than standara premiums or an exclusion applied lon heath grounds? by pcesenty receving 2 disabitty lbeneft or incapable for work or have ever made an ineurancectaim | OYes ONo | OYes ONo | OYesONo |OYes ONo |OYes ONo | OYesONo for disability, accident, medical care Jor extiat ness and/or other insurance benetts? ie insured) Nae EEN LUSeECe [Disetosure: In accordance withthe Insurance Commision’ Cireular Letter No. 2016-54, your medical information willbe uploaded to a Medical information Database accessibe to life insurance companies for the purpose of enhancing risk assessment and preventing fraud. Once uploaded, al le insurance companies will only have limited access to your information in order to protect your right to prioaey in accordance with law. copy of Circular Letter No. 2016-54 may be accessed at the Insurance Commission's website at ww.insurance gov.ph Please enswer al the questions in ull and tothe best of your knowledge. if you are uncertain about whether the additional information you have fs ‘necessary tobe declared, please declare anyway. Itcan only help us determine If our product wil cater to your specific requirements. Proposed _ | Family Member |Family Member] Family Member |Family Member] Family Member | Principal Insured 4. 2 3 4 5 Ptease write down in the space provided the names ofthe persons tobe insured according to tne sequence in the previous pages. 1) Has the person to be insured ever been treated for or ever had ary sign or symptom of, or undergone consultations, investigations, Imacicaton, monitoring or advice for ANY| or tne foiowing: a) Brin or Nervous System Disorer/Oisease suchas Aeneimers | O¥es ONo | O¥es ONo | OYesONo | Oves ONo |Oves ONo | OYes ONO Disease, Amyotrophic Lateral Sclerosis as}, cerebral Palsy, Dementia, Hyerocephatus, Mutipie Sclerosis, Myasthenia Gravis Parkinson's Disease, Muscular ystrophy fb) Menta Heath Disorder suc as Psychosis, Schizophrenia, Depression | Oves ONo | OYes ONo | OYesONo No | OYes ONo | Ov attention Defic Disorder (ADDI / “ es ® Over Olle |OveGNo | OvwGNe ention Deis Hyperactivity Dtsorder aot) =) Blood and Lymphatic Systam Disorder such as Hodekin's Lymphoma, Mutipie | O¥es ONo | O¥es ONo | OYesONo | OYes ONo |OYes ONo | OYes ONO Myeloma, Thalassemia, Antishosphliic| Syndrome (APAS) 2) cancer of any woe, Materanttumer, | Yes ONo | O¥es ONO | OvesONe | Oves ONo |Oves Ono | OYesONe Je) chronic Respiratory Conitions such cece Cee rear Oves ONo | Ces ONo | OvesONo | Oves ONo |OYes ONo | OYes ONO bisease, cronic Asthma, Chronic, Bronchitis, Emphysema No 5 Disorders 1 beinesl Ue, Deafness Glavesma, | O¥es ONo | OYes ONo | OvesONo | Oves ONo |Oves ON | Ces ONo Retinal Detachment, Meniere's Disease/SyncromeApplication Form for Global Health Access Application Number H Proposed Principal insured amy Member Femty Member Family Member 3 Family Member] ‘ Family Member] 5 Please wrte down in the space provided Je names ofthe persons tobe insured accoraingo the sequence inthe prewaus pages. |e) Heart and/or Covebvovascuar disease Such as Angina (chest pain). Hear tack, Atcomine! Aor Aneurysm laa, Ariat Fbriiation| lar-Cerebrovascuar Rosie (CVA) or stroke incusing Transient lchemie attack 74), Carciomyopaty, Supraventculr Tachycarala (V7) Murmurs, Hear Faure, Hear VaNvuor Disease such as Valvular Irsu ciency Resurstation, Mizal Vawe Prolapse), aonoemalHesre Beat, or ony Hear/Blood Vascular Diseases. Oves ONe Oves Ono Oves ONe Oves One Oyes One Oves ONe Ih) Gastrointestinal Disorder such as Live Gems, Fatty Liver, Colts (Ulcerative, Ctotn’s Disease, Hepes 8, Hepatitis © Oves ONe Oves ONo (Oves ONe Oves ‘ONo OYves ONo ‘OYes ONo h Kicney and Urinary Tract Disorder such as Chron Renal Fature,Chrone Keney [Pisease, Polycystic cney Disease Oves ONo (Oves ONo (Oves ONo Oves (ONo (ves ONo ves ONo [Ht ADS, AIDS Related Complex or any citer AIDS related condition Oves ONo (Ove ONo (OYes ONe Oves Ono Oves ONo Yes ON ky Hypertension rign Blood Pressure), High Chotestorl, ysiidemia, Oves ONe (Oves ONo (OYes ONo Oves ‘No (Oves ONo ‘ves ONo I Diabetes, other Endocine Disowers mpores Givose Tolerance, Impaired Fasting Giucose OYes ONe (OYes ONo (OYes ONe Oves Ono OYes ONo OYes ON rn) Musculoskeletal Diseases and autarmmune Diseases such as Systemic Lupus Enthematasus, Psoriatic Artis, IRroumatid anes, Dematomyosti, Mast cel Actvaton Syndrome (MCAS), Degenerative Joint Disease OYes ONo (OYes ONo (OYes ONo Oves ONo (Yes ONo (OYes ONo hy congenital Disorders such Down's Synerome ves ONo Oves ONo Oves ONo Ores (ONo ‘Oves ONo OYes ONo 0) Transplantations, Posthetis implants appliances in the body e. shunts, pacemakers, orjont replacements) Oves ONo (OYes ONo (OYes ONo Oves (ONo (OYes ONo ‘Yes ON 2) Other than those aeady dscosed etsehare inthis frm, has the person tobe insured a) Ever boon prescribe, advise. lindergone any medication oc medical reatment OYves ONo Oves ONo (Oves ONo Oves ‘No OYes ONo ‘ves ONo by Current taking any mecication or medical treatment whether prescribed or not? OYes ONo (OYes ONo (Ove ONo Oves (No Oves ONo (Yes ON 5) other than those aveady ascosed eisewhere inthis form, nas the person [tobe insure: 2) Ever been hospitalized tor more than ve (6) days oF Yes ONo OYes ONo (Oves ONe Oves (No Oves ONo ‘Yes ONo >) uncergone any surgery or Outpatient procedures of any kino, such as but not limited to, eatarat extraction, excision or mass o tumor, chemotnerop, neiion and eranage, colonoscopy and other endoscopic procedures, biood transfusion, ophthalmologic procedures, casting emadialysis, aatation a curatage acioactve iodine tneraoy, ee OYes ONe Ove ONo (O Yes ONe Oves No Yes ONo ‘Yes ON 4ofi7Application Form for Global Health Access Application Number H Proposed Principal nsurod Family Member 1 Famiy Member 2 Family Member 3 [Femty Member] 4 Family Member] 5 tenses fhe persons tobe insred eccrango the sequence nthe previous pages fas the persn tobe awed a) ever nad esute/nvestigtions [not are esos rh fl ext he eterence range fo example but not ime to psy endoscopy. pao smear, Jrammogam, breast utrascund, Prostate Specie Antigen (PSA) tat, prostate examination tumor mare, ooo test, cancer screening ex, est chek or patholo Oves Ono ves Ono Oves Ono. ves Ono Oves Ono ves Ono le) _camenty wating ine competion Jor resus oF any medial nvestizaion or atgroste esa ves ON Oves ON Oves One: Yes ONe Oves One (Oe One. irtenaing to seek or cunt soaking ery meen sie, examination, of procure cher non snl Pye sam or Excuthe Check up? Ove ONo Oves ON Oves Ono: OYes ONe (Oves One Ove Oe: