Has the person to be insured

1. Ever had a life, health or critical illness application that has was declined,
deferred, or accepted with higher than standard premiums or an exclusion applied on
health grounds?

2.
Presently receiving a disability benefits or incapable for work or have ever made
an insurance claim for disability, accident, medical care or critical illness
and/or other insurance benefits?

3. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Brain or Nervous System Disorder/ Disease such as

Alzheimer's Disease, Amyotrophic Lateral Sclerosis (ALS), Cerebral Palsy, Dementia,
Hydrocephalus, Multiple Sclerosis, Myasthenia Gravis, Parkinson's Diseas, Muscular
Dystrophy?

4. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Mental disorder such as Psychosis, Schizophrenia, Attention Deficit

Disorder(ADD) / Attention Deficit Hyperactivity Disorder (ADHD)?

5. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Blood and Lymphatic System Disorder such as Hodgkin's Lymphoma, Multiple Myeloma,
Thalassemia, Antiphospholipid Syndrome (APAS)?

6. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Cancer of nay type, Malignant tumor, Leukemia?

7. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Chronic Respiratory conditions such as Chronic Obstructive Pulmunary Diseas,

Chronic Asthma, Chronic Bronchitis, Emphysema?

8. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Eye, Ear, Nose and throat Disorder such as Corneal Ulcer, Deafness, Glaucoma,
Retinal Detachmelnt, Meniere's Disease / Syndrome?

9. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:
Heart and/or Cerebrovascular disease such as Angina (Chest Pain), Heart Attach,
Abdominal Aortic Aneurysm (AAA), atrial Fibrillation (AF), Cerebrovascular Accident
(CVA) or strooke including Transient Ischemic Attack (TIA), Cardiomyopathy,
Supraventricular Tachycardia (SVT), murmurs, Heart Failure, Heart Valvular Disease
(such as Valvular Insuciency/ Regurgitations, Mitral Valve Prolapse), Abnormal
Heart Beat, or any Heart/Blood/ Vascular Diseases?

10. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Gastrointestinal Disorder such as Liver Cirrhosis, Fatty Liver, Colitis

(Ulcerrative), Crohn's Disease, Hepatitis B, Hepatiotis C?

11. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Kidney and Urinary Tract Disorder such as Chronic Renbal Failure, Chronic Kidney
Disease, Polycystic Kidney Disease?

12. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), AIDS

Related Complex or any other AIDS related condition?

13. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Hypertention (High Blood Pressure), High Cholesterol, Dyslipidemia?

14. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Diabetes, other Endocrine Disorder Impaired Glucose Tolerance, Impaired Fasting

Glucose?

15. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Musculoskeletal Diseases and Autoimmune Diseases such as Systemic Lupus

Erythematosus, Psoriatic Arthritis, Rheumatoid Arthritis, Dermatomyositis, Mast
Cell Activation Sysndrome (MCAS), Degenerative Joint Disease?

16. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:

Congenital Disorders such as Down Syndrome?

17. Has the person to be insured ever been treated for or ever had any sign or
symptoms of, or undergone consultations, investigations, medications, monitoring or
advice for ANY of the following:
Transplantations, Prosthetic implants & appliances in the body (e.g. shunts, pace-
makers, or joint replacement)?

18. Other than those already disclosed elsewhere in this form, has the person to be
insured: ever been prescribed, advised, or undergone any medication or medical
treatment?

19. Other than those already disclosed elsewhere in this form, has the person to be
insured: Currently taking any medication or medical treatment whether prescribed or
not?

20. Other than those already disclosed elsewhere in this form, has the person to be
insured: Ever been hospitalized for more than five (5) days or?

21. Other than those already disclosed elsewhere in this form, has the person to be
insured: Undergone any surgery or Outpatient procedures of any kind, such as but
not limited to, cataract extraction, excision of mass or tumor, chemotheraphy,
incision and drainage, colonoscopy and other endoscopic procedures, blood
transfusion, ophthalmologic procedures, casting, hemodialysis, dilatation and
curettage, radioactive iodine theraphy, etc?

22. Has the person to be insured:

Ever had results/investigations that are abnornalor that fall outside the reference
range, for example but not limited to biopsy, endoscopy, pap smear, mammogram,
breat untrasound, Prostate-Specific \Antigen (PSA) test, prostate examination,
tumor marker, blood tests, cancer screening tests, health checks, or pathology;?

23. Has the Person to be insured:

Currently awaiting the completion or results of any medical investigations or
diagnostic tests;?

24. Has the person to be insured:

Intending to seek or currently seeking any medical advice, examination, or
procedure other than Annual Physical Exam or Executive Check up?

25. Do you or any of your dependents/s smoke cigarettes/e-cigarettes/vape/smokeless

tobacco? of yes, indicate the number of sticks/ packet per day, ml per day and
number of years.?

26. Are you and/or your immediate family member entrusted with appointive or
elective position in the Philippines or in a foreign state, a senior politician,
judicial or military official, senior executive of government or state-owned or
controlled corporations or political party official?