AXA PHILIPPINES

CLIENT INFORMATION SHEET

Policy Insured Policy Owner
Full Name ( Last, First, Middle)
Other Name (Maiden Name, Alias)
Date of Birth (yyyy/mm/dd)
Place of Birth
Nationality
Single Married Male Singl
Single Married Male
Civil Status and Sex Widowed Divorced/Annulled Female Widow
e Divorced/Annulled Female
ed
Wido
Height and Weight Height____ft.___in. Weight_____lbs. Height____ft.__in. Weight_____lbs.
wed
Occupation (Exact position)
Monthly Income
SSS/GSIS Number
Tax Identification Number

Complete Residence Address

Business / Company Name

Complete Business/Company Address

E-mail Address/ Mobile No. Email: Mobile No.: Email: Mobile No.:
Telephone Number and/or Fax Number Tel No.: Fax No: Tel No.: Fax No:

Name of Spouse (if married) Age: Age:

Occupation (s) Monthly Income: Monthly Income:
Inforce Life Insurance Amount of Coverage: Amount of Coverage:

Beneficiary/ies 1 2 3 4
Full Name (Last,First,Middle Name)

Complete Residence Address

Gender Female Male Female M Female Male Female

Male
a
l
e
 Male M
Birthday (mm/dd/yyyy) / / / / a/ / / /
Place of Birth l
Contact Number e
Occupation
Relationship to Proposed Insured
Type of Beneficiary(Primary/Secondary)
Benefit %

Payment Instructions :
Annual Quarterly Credit Card
Mode of Payment: Method of Payment: Auto-Debit Arrangement (ADA)

Semi-Annual Monthly Post Dated Check (PDC) Cash

Declaration of Proposed Insured and Owner
Proposed Insured Proposed Owner If "YES"
YES NO YES NO please indicate details
1. Do you smoke cigarettes/cigards?
no of Sticks/day : no of years :
(If yes, indicate no.of sticks/day & no. of years) PI: _____ PI: _____ PO:____
2. In The last 2 years, have you: PO:____

a. Consulted a medical doctor or been referred for tests or Reason:

investagation or had any medical test/s? Diagnosis:
Medication:
Result of Diagnostic Test Done:
Current State of Health:
Name of Doctor:

b. In the last 2 years, have you been diagnosed, or received

treatment, medication or advise pertaining to unexplained Condition:
Date Diagnosed:
weightloss, high blood pressure, heart or lung disease, Medication:
diabetes, tumor or cancer, mental or neurologic dysfunction, Results of Diagnostic Test:
Date of Test:
liver disease, or any other ailment with or without
Current State of Health:
physical impairment?
3. Have you had at least 2 immediate family members
Relative:
(parent or siblings) who were diagnosed or Age:
died of hypertension, diabetes, heart or kidney disease, Condition:
Living/Deceased?:
mental illness or cancer or any diseases no mentioned above
prior to age 50?
4. Including this new application, is your total insurance
cover above Php3m?
If yes, please provide the company name, product type and/or
 riders, amount of coverage and issue date?
5. In the last 2 years, have you participated in sky/scuba diving,
bungee jumping, motor racing or hazardous sports or activities
for more than 3x?
6. Are you and/or your immediate family member entrusted with
appointive or elective position in the Phlippines 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?
7. Have you been involved or included in any lawsuit
or court litigation?
For Female Applicant Only: If yes, how many months?
8. Are you currently pregnant?
Expected delivery date:

Additional Information for Assessment:

1. What is you purpose for getting an Insurance Coverage? (Education, Retirement, Health, Income Protection - You may choose more than one) ____________________________________________
2. Ideally we recommend that you set aside 10% of your gross income for insurance, in your case, how much are you willing to set aside monthly for your coverage? (Range will do) _____________

3. Just to set expectations, availing a personal insurance coverage is going to be a long term commitment if you want to see your money grow, how many years are you wiiling to pay for your premiums? (10yrs,
20yrs, 30yrs, lifetime) _______________________________________________________________________________________________________________________________
4. How much coverage would you like to avail for your insurance protection, should your untimely demise happen? (1M, 2M, 5M, 10M, 15M, 20M etc) _________________________________________
5.What kind of protection are you looking forward to avail? You may choose more than one of the following.
[ ] Protection from Critical Illnesses
[ ] Hospitalization Benefits should you be confined
[ ] Personal Accident Claims
[ ] Waiver of Premium (Policy will be kept in forced as if it were continuosly paid for should you become Totally & Permanently Disable)
[ ] Added Death Benefit for a minimum cost
[ ] Others: Please specify _________________________________________________________________________________________________________