Application for Life Insurance

Individual Insurance
PRU LIFE INSURANCE CORPORATION OF U.K.
REMINDERS: 9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
Please use CAPITAL LETTERS and black ink. 1634 Taguig City, Philippines
Tick the appropriate box to indicate your choice. Customer helpdesk: (632) 8683 9000, (632) 8884 8484, (632) 8887 LIFE
Please do not sign on a blank form. within Metro Manila, 1 800 10 PRULINK for domestic toll-free
If not applicable, put “N/A” in all empty fields. Email: contact.us@prulifeuk.com.ph Website: www. prulifeuk.com.ph
CLIENT NUMBER (Policyowner)

AGENT INFORMATION (FOR AGENT'S USE ONLY)

SURNAME, GIVEN NAME AGENT CODE BRANCH

DETAILS OF LIFE INSURED DETAILS OF POLICYOWNER (Accomplish this section only if the Policyowner is
different from the Life Insured)

SURNAME SURNAME

GIVEN NAME GIVEN NAME

MIDDLE NAME MIDDLE NAME

OTHER LEGAL NAME/ALIAS OTHER LEGAL NAME/ALIAS

GENDER CIVIL STATUS SALUTATION GENDER CIVIL STATUS SALUTATION

Male Single Married Male Single Married

Female Others Female Others

DATE OF BIRTH (mm/dd/yyyy) AGE NATIONALITY DATE OF BIRTH (mm/dd/yyyy) AGE NATIONALITY

PLACE OF BIRTH (City/province, country) TIN/SSS/GSIS PLACE OF BIRTH (City/province, country) TIN/SSS/GSIS

OCCUPATION (State exact duties; if member of AFP/PNP, state rank) OCCUPATION (State exact duties; if member of AFP/PNP, state rank)

NATURE OF WORK OR NATURE OF BUSINESS (If self-employed) NATURE OF WORK OR NATURE OF BUSINESS (If self-employed)

EMPLOYER EMPLOYER

NATURE OF BUSINESS OF EMPLOYER NATURE OF BUSINESS OF EMPLOYER

GROSS ANNUAL INCOME (In PhP) SOURCES OF FUNDS GROSS ANNUAL INCOME (In PhP) SOURCES OF FUNDS
Salary Business Salary Business

NET WORTH (In PhP) Others NET WORTH (In PhP) Others
(If premium payments come from a (If premium payments come from a
third-party payor, please accomplish KYC third-party payor, please accomplish KYC
for Beneficial Owner Form) for Beneficial Owner Form)

Do you currently file a tax return in the United States Yes No Do you currently file a tax return in the United States Yes No
of America? Please provide necessary FATCA documents. of America? Please provide necessary FATCA documents.
MOBILE NUMBER MOBILE NUMBER

EMAIL ADDRESS EMAIL ADDRESS

PAGE 1

II01
DETAILS OF LIFE INSURED (Accomplish this section only if the Policyowner
DETAILS OF POLICYOWNER is different from the Life Insured.)

PRESENT ADDRESS (Number, street, municipality/city, province) PRESENT ADDRESS (Number, street, municipality/city, province)

COUNTRY ZIP CODE COUNTRY ZIP CODE

Tick if same as Tick if same as

PERMANENT ADDRESS (Number, street, municipality/city, province) present address PERMANENT ADDRESS (Number, street, municipality/city, province) present address

COUNTRY ZIP CODE COUNTRY ZIP CODE

Tick if same as Tick if same as

BUSINESS/EMPLOYER ADDRESS (Number, street, municipality/city, province) present address BUSINESS/EMPLOYER ADDRESS (Number, street, municipality/city, province) present address

COUNTRY ZIP CODE COUNTRY ZIP CODE

In the next 12 months, do you expect to change your: In the next 12 months, do you expect to change your:

a. occupation? Yes No a. occupation? Yes No

b. country/province/city/municipality of residence? Yes No b. country/province/city/municipality of residence? Yes No

If yes to (a) and/or (b), provide details. If yes to (a) and/or (b), provide details.

PREFERRED POLICYOWNER’S ADDRESS FOR CORRESPONDENCES RELATIONSHIP OF POLICYOWNER TO LIFE INSURED

(Fill this out only if the Policyowner is
Present Permanent Business/Employer different from the Life Insured)

DETAILS OF BENEFICIAL OWNER

Beneficial Owner refers to any natural person who ultimately owns or controls the customer, and/or on whose behalf a transaction or activity is being conducted, or has ultimate
effective control over a legal person or arrangement.

In relation to an entity, Beneficial Owners are individuals either owning or controlling more than 25% of the company’s shares or voting rights.

Do you have a Beneficial Owner? Yes No If “YES”, please accomplish KYC for Beneficial Owner Form.

DETAILS OF PRIMARY AND SECONDARY BENEFICIARIES

If any beneficiary designation is “IRREVOCABLE”, please accomplish the Endorsement for Designating Irrevocable Beneficiary Form. If more than one
Beneficiary is named, equal sharing shall be presumed unless stated otherwise.

SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER

Male Female

RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH NATIONALITY
Primary Secondary Revocable Irrevocable

PRESENT ADDRESS (number, street, municipality/city, province) Tick if same as Policyowner ZIP CODE

SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER

Male Female

RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH NATIONALITY
Primary Secondary Revocable Irrevocable

PRESENT ADDRESS (number, street, municipality/city, province) Tick if same as Policyowner ZIP CODE

If there are more than two (2) Primary and/or Secondary Beneficiaries, additional space is provided on page 3 under the OTHER DETAILS/COMPANY ENDORSEMENT section.

PAGE 2
POLICY INFORMATION

NOTE: Benefits must be consistent with the submitted Sales Illustration Form/Quotation Proposal.

PLAN NAME SUM ASSURED CURRENCY

PhP USD

BENEFITS AND AMOUNT

Accelerated Total and Crisis Cover Waiver Payor Term Benefit

Permanent Disability
(TPD)

Accidental Death and Life Care Advance Payor Waiver of

Disablement Benefit Plus Regular Premium

Accelerated Life Care Life Care Plus Renewable

Benefit Convertible Level
Term Assurance Benefit

Additional Term Rider Life Care Waiver Waiver of Premium

on TPD

Crisis Cover Benefit Multiple Life Care Others (Specify below)

Plus

Crisis Cover Plus Non-accelerated

Benefit for Term Total and Permanent
Disability Benefit

VARIABLE LIFE RIDER AND AMOUNT

No. of years to be billed
Variable Life Rider Variable Life Rider
(One-off Premium)* (Regular Premium)*

*Note: You will be regularly billed the Variable Life Rider Premium you indicated for the period you specified. If you no longer wish to be billed for future regular payments,
you may notify the Company by written request. Because the Variable Life Rider payments are optional, the Policyowner has the option not to make future Variable Life
Rider payments after the first payment. Failure to make subsequent Variable Life Rider payments will not cause the Insurance Policy or Variable Life Rider to lapse.

HOSPITAL INCOME BENEFITS AND AMOUNT

Others (Specify below)

Daily Hospital Surgical Expense
Income Benefit Benefit

Intensive Care Unit Long-term

Benefit Hospitalization
Benefit

PERSONAL ACCIDENT BENEFITS AND AMOUNT

Accidental Death and Field Trip Coverage Total and Permanent

Disablement Benefit Disability

Dangerous Sports Medical Others (Specify below)

Coverage Reimbursement
Benefit

Double Indemnity Murder and Assault

Benefit Benefit

PREMIUM INFORMATION

ANNUALIZED PREMIUM INITIAL PREMIUM PAID MODE OF PAYMENT METHOD OF PAYMENT (PREMIUM RENEWAL)
Annual Semi-annual Credit card Auto-debit arrangement Cheque
Quarterly Monthly Cheque/PDC Cash Others

NON-FORFEITURE OPTIONS (FOR TRADITIONAL PLANS ONLY) DIVIDEND OPTIONS (FOR TRADITIONAL PLANS ONLY)

Unless otherwise indicated below, Reduced Paid-up Insurance is Unless otherwise indicated below, Left to Accumulate and Earn Interest is automati-
automatically assumed. cally assumed.

Premium Loan Option Cash Surrender Value Paid in Cash Used to Buy Paid-up Insurance
Extended Term Insurance Used to Pay a Portion of Premium

I agree to use any dividend accumulation of the Policy towards any non-forfeiture option in effect.

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PERSONAL HISTORY

If you answer "YES" to any of the following questions, please indicate the question number and indicate details in the space provided.

1) Have you: Life Insured Policyowner Details of “YES” answer

a. flown in an aircraft other than as a passenger? (If yes, complete an Aviation Questionnaire) Yes No Yes No
b. driven a motorcycle or engaged in scuba diving, bungee jumping, or other hazardous
Yes No Yes No
sports? (If yes, complete pertinent questionnaire)

c. been active in politics as a candidate or in any other capacity during the last five (5) years? Yes No Yes No
d. ever made an application for life insurance or reinstatement thereof which was declined,
Yes No Yes No
postponed, cancelled, or modified in kind, amount, or rate?

e. received any threat in your life, person, or safety? Yes No Yes No

f. do you have any pending application with other insurance companies? Yes No Yes No
2) What insurance(s) is/are now in force on the life of Life Insured? Company Amount of coverage Rider(s)/Year issued

3) Has there been or will there be any change in any existing insurance in force? Yes No

4) Will premiums for the insurance applied for be paid by a policy loan from any existing policy? Yes No

NOTE: If answered “YES” to questions 3 and/or 4, please accomplish the Replacement Notification section in page 8.

YOU ARE TO DISCLOSE IN THIS APPLICATION FORM (AND IN ANY PERSONAL STATEMENT CONCERNING HEALTH MADE TO THE COMPANY OR TO THE MEDICAL EXAMINER
OF THE COMPANY) FULLY AND FAITHFULLY ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE THE POLICY ISSUED HEREUNDER MAY BE RESCINDED.

FAMILY HISTORY DETAILS (This section need not be answered if medical examination is performed)

LIFE INSURED POLICYOWNER (if applying for Payor Waiver and/or Payor Term)
Family Condition/Illness Age at Cause of death Age at Family Condition/Illness Age at Cause of death Age at
members onset death members onset death
Father Father
Mother Mother
Spouse Spouse

Siblings Siblings

Children Children

HEIGHT AND WEIGHT (This section need not be answered if medical examination is performed)

LIFE INSURED POLICYOWNER (if applying for Payor Waiver and/or Payor Term)
HEIGHT WEIGHT Have you lost weight during the HEIGHT WEIGHT Have you lost weight during the
past 12 months? Yes No past 12 months? Yes No
ft. in. lbs. ft. in. lbs.
Reason and amount Reason and amount
(lbs.) of weight loss (lbs.) of weight loss

NON-MEDICAL QUESTIONNAIRE FOR ADULTS (AGES 18 & ABOVE) (This section need not be answered if medical examination is performed)

If you answer "YES" to any of the following questions, please indicate the question number and provide details as to the nature of illness, operation or treatment, date and
duration, severity and results, and name and address of attending physician/s, clinic/s or hospital/s. Note that Policyowner portion should only be
answered if applying for Payor Waiver and/or Payor Term.

1) Have you: Life Insured Policyowner Details of “YES” answer

a. within the past five years, consulted or been treated or examined by any physician
Yes No Yes No
or medical practitioner?
b. ever had x-ray, electrocardiogram, blood studies, or other diagnostic tests? Yes No Yes No
c. ever been in a hospital, clinic, sanitarium, or institute for observation, diagnosis,
Yes No Yes No
operation, or treatment?
d. had or been told you had Acquired Immune Deficiency Syndrome (AIDS), AIDS-related
complications, or AIDS-related conditions? Yes No Yes No

e. had any form of Sexually Transmitted Disease (STD)? Is there anything in your lifestyle
which could expose you to risk of AIDS? Yes No Yes No

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NON-MEDICAL QUESTIONNAIRE FOR ADULTS (AGES 18 & ABOVE) (This section need not be answered if medical examination is performed)

Life Insured Policyowner Details of “YES” answer

f. been tested positive for antibodies to the AIDS virus? Yes No Yes No
g. had any abnormality, deformity, disease, or disorder? Yes No Yes No
h. received and/or is presently receiving treatment or taking medication of any kind? Yes No Yes No
i. ever drank alcoholic beverages, taken habit-forming drugs, or sought advice or treatment
for alcoholism, drug habit or other addiction? Yes No Yes No

i) Drugs Yes No Yes No

ii) Alcohol intake per week (If yes, provide details) Yes No Yes No
wine (no. of glasses)
beer (no. of 350 mL glasses)

hard liquor (no. of shots)

j. smoked cigarettes/tobacco within the past year? (If yes, provide details) Yes No Yes No
i) How many years have you smoked/been smoking cigarettes and/or tobacco?
(Please include past smoking history)
ii) What is the average number of sticks you smoke daily?

2) Have you ever had or been told that you had or sought advice for:

a. dizziness, fainting spells, epilepsy, nervous breakdown, severe headaches, or any disease or Yes No Yes No
disorder of the brain or nervous system?
b. asthma, hay fever, chronic cough, spitting of blood, tuberculosis, or any disease or disorder of the lungs Yes No Yes No
or respiratory system?
c. high blood pressure, chest pain, shortness of breath, heart murmur, or any other disease of the heart Yes No Yes No
or circulatory system?

d. any disease or disorder of the stomach, intestines, bowel, rectum, appendix, liver, or gallbladder? Yes No Yes No

e. nephritis, kidney stone, or any disease or disorder of the kidney, bladder, or prostate? Yes No Yes No
f. diabetes, thyroid, or other endocrine disorders? Yes No Yes No
g. arthritis, rheumatism, or any disease or disorder of the back, spine, bones, joints, or muscles? Yes No Yes No

h. cancer (including carcinoma in situ) or a tumor or ulcer of any kind or any abnormal tissue growth? Yes No Yes No

i. varicose veins, varicose ulcers, phlebitis, or hernia of any kind? Yes No Yes No
j. any disease or disorder of the eyes, ears, nose, or throat? Yes No Yes No
k. any other serious illness, disease, injury, or surgery not mentioned above? Yes No Yes No
3) FOR WOMEN ONLY

a. Are you pregnant? Yes No Yes No

b. Any abnormality in menstruation, pregnancy, or of the breast or reproductive organs? Yes No Yes No

NON-MEDICAL QUESTIONNAIRE FOR MINOR LIFE INSURED (AGES 0 - 17)

Answer Details of “YES” answer

1) Was the child's birth abnormal or premature? If “yes”, please provide details below.
Yes No
Weight at birth lbs. Number of months premature

2) Has the child ever been treated for, or ever had any indication of:

a. disorder of eyes, ears, nose, mouth, or throat; or slow physical or mental development? Yes No
b. epilepsy, febrile fits, or any other disorders of the brain or nervous system? Yes No
c. asthma, bronchitis, tuberculosis, or respiratory disorder? Yes No
d. rheumatic fever, heart defects, anaemia, or disorder of the blood, and other diseases of the heart or blood vessels? Yes No

e. diabetes, disorder of the stomach, intestines, kidney, bladder, reproductive organs, liver, gallbladder, or pancreas? Yes No
f. severe skin infections, enlarged glands, growth, cyst, tumor/cancer? Yes No
g. disorder of the muscles or bones, spine, back or joints, deformity, lameness, or amputation? Yes No
3) a. Has the child ever had any illness or injury lasting or requiring treatment for more than seven (7) days, or been
admitted to a hospital or medical facility? Yes No

b. Has the child ever been referred to any specialist or hospital? Yes No
c. Has the child ever had or been advised to have any electrocardiogram (ECG), x-ray, blood or urine test,
biopsy, AIDS test, or other diagnostic test? Yes No

d. Is the child currently receiving medical treatment or under medical care of any kind? Yes No

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NON-MEDICAL QUESTIONNAIRE FOR MINOR LIFE INSURED (AGES 0 - 17)

4) Please provide the name, address, Name of doctor Address and other details
and other details of the child's
usual doctor(s). If none, provide
details of the last doctor consulted.

5) How long has he/she known

the child? Number of years

6) When and for what reason did Reason for consultation Result of consultation
the child last consult him/her?

Date of consultation (mm/dd/yyyy) If under treatment, indicate the nature and duration of treatment.

7) a. Has any proposal for life or health insurance on Name of company

the child's life, or for insurance against accident
or critical illness ever been made to Pru Life UK Yes No
and/or any other insurance company?

b. Has any such proposal ever been declined, Name of company Reason
deferred, or accepted at special rates? Yes No

OTHER DETAILS/COMPANY ENDORSEMENT

DECLARATION OF UNDERSTANDING

PLEASE READ CAREFULLY BEFORE SIGNING THE APPLICATION FORM:

By signing this Application, I, (i.e. each of the Policyowner and Life Insured) declare, agree to, and authorize the following:
1. All the statements and answers in this Application and any information given to Pru Life UK or its medical examiners, including any amendments, are complete, true, correct, and binding
on all parties in interest under the Policy applied for.
2. Pru Life UK reserves the right to request for additional medical evidence to assess my health. Any physician, hospital, clinic, or medical organization is authorized to furnish Pru Life UK with any medical
information pertaining to me.
3. Prior to the issuance of the Policy applied for, I agree to inform Pru Life UK of any change in my (a) state of health, and (b) occupation or activities.
4. If a material fact is not disclosed in this Application, the Policy issued may not be valid. I understand that if in doubt as to whether a fact is material, it will be disclosed to Pru Life UK.
5. The insurance coverage will not commence until this Application has been approved, the initial premium has been received by Pru Life UK, and the Policy has been issued while I am in good health.
6. I will update Pru Life UK in a timely manner of any change in details previously provided especially with respect to a change in citizenship, tax status, or tax residency. If the Policyowner is a corporation,
changes in registered address, address of place of business, substantial shareholders, legal or beneficial owners who own or control more than
10% of the Policyowner will also be disclosed.
7. I confirm that the benefit illustration, quotation proposal, product summary, and other relevant sales materials relating to this Application were received, completely and clearly explained, and
fully understood.
8. The amounts to be invested in the Policy have been declared to relevant tax authorities and were not derived, directly or indirectly, from illegal activities or sources and/or tax evasion.
9. This Application is subject to the guidelines on anti-money laundering and financial underwriting. Pru Life UK can disapprove this Application or terminate the Policy if I fail to provide the
necessary information relating to the Application or relevant transaction or if the Application violates the said guidelines.
10. If this Application is declined by Pru Life UK, its only obligation is to return the premium paid. If the Application is cancelled for failure to submit requirements, Pru Life UK will return the premium
paid less fees for medical examinations it incurred.
11. I accept, agree with, and understand the features, benefits, nature, limitations, exclusions, risks, terms, and conditions of the Policy, product and attached riders. For unit-linked products, the next
computed unit price following the issue date of the Policy will be applied.
12. I agree to receive financial and other policy-related information through the mobile number and email address provided to Pru Life UK. In addition, I agree to be pre-registered to PRUaccess, an
online facility that will enable me to manage and request certain transactions involving policy.

I acknowledge that PRU Life UK shall not be liable for claims or liabilities incurred as a result of the dissemination of my personal information through the said facilities. I understand that if I no
longer wish to recieve such information or notification through email or mobile and/or be registered to PRUaccess, I may contact Pru Life UK at telephone numbers (632) 8683 9000, (632) 8884 8484,
(632) 8887 LIFE within Metro Manila, 1 800 10 PRULINK for domestic toll-free or email contact.us@prulifeuk.com.ph.

PAGE 6
DECLARATION OF UNDERSTANDING

DATA PRIVACY
For purposes of this Section:
a. “Pru Life UK” shall refer to Pru Life Insurance Corporation of U.K., its directors, officers, employees, insurance agents, insurance brokers, other agents and representatives,
reinsurers, contractors, legal advisers, and Pru Life Insurance Corporation of U.K.’s subsidiaries, affiliates and other related entities, and their directors, officers, employees,
insurance agents, insurance brokers, other agents and representatives, contractors, and legal advisers.
b. ”Data subject” shall mean any or all of the Policyowner, the Life Insured, the Beneficial Owner, Beneficiary/ies, and all other individuals whose personal information or personal
sensitive information is or will be disclosed to Pru Life UK for processing, which may either be manual or automated, in relation to the issuance, implementation and handling of
insurance policies, direct marketing, profiling, risk assessment, underwriting and administration of insurance coverage and claims, data analytics and data sharing with Pru Life UK.
1. I, together with all other data subjects (“We”), hereby consent to the manual or automated processing of our personal information and/or sensitive personal information by Pru Life
UK, within or without the Philippines, in accordance with the Data Privacy Act and its implementing rules and regulations and the publicly available Pru Life UK privacy policy found
in the company website at www.prulifeuk.com.ph, for the purposes deemed fit by Pru Life UK, which shall include issuance, implementation and handling of insurance policies, direct
marketing, profiling (which includes product and other offers), risk assessment, underwriting and administration of insurance coverage and claims, data analytics, and data sharing
with Pru Life UK.

2. We hereby authorize Pru Life UK to disclose our particulars or any information to any Authority (governmental and other regulatory authority or self-regulatory body in various
jurisdictions) in connection or adherence (whether voluntary or otherwise) with Applicable Requirements (laws, regulations, orders, guidelines, codes, market standard, good practices
and requests of or agreements with any Authority as promulgated and amended from time to time). Such disclosures may be effected directly or sent through any of Pru Life UK’s
Head Office(s) or other related corporations, or in such manner as may be deemed fit. For purposes of the foregoing and notwithstanding any other provision in this Application or
any other agreement between the parties, Pru Life UK may need us to provide further information or documents as may be required for disclosure to any Authority and we shall
provide the same Anti-Money Laundering Act of 2001, the E-Commerce Act of 2000, the Philippine AIDS Prevention and Control Act, the Magna Carta for Disabled Persons,
Presidential Decree No. 1718, and any other applicable data protection legislation from time to time in force (“Data Privacy Laws”).

3. Pru Life UK, its duly authorized processors such as but not limited to contractors for services providing anti-money laundering systems, claims investigation, photocopy and scanning,
courier, and printing, and reinsurers are allowed to use, collect, store and process our personal and sensitive personal information obtained by Pru Life UK pursuant to this Application
or Policy issued by Pru Life UK for legitimate purposes such as underwriting and administration of insurance coverage and claims and processing of after sales transactions. Any such
information collected may be retained by the aforementioned parties until ten (10) years from the date of maturity or termination of the Policy or date of denial of this Application,
whichever comes earlier.

4. We warrant that the consent of the Beneficial Owner (if any), Beneficiary/ies and all other data subjects were obtained for the use, storage and processing of their information for
purposes of compliance with regulatory requirements, the processing of this Application, and administration of the Policy issued. I undertake to provide Pru Life UK with proof of my
authority to give the required consents of the other data subjects with respect to the disclosure and processing of their personal information and/or sensitive personal information
for the legitimate purposes set out in this Application or in the Policy issued by Pru Life UK.

5. In accordance with the Insurance Commission’s Circular Letter No. 2016-54, we understand that our medical information will be uploaded to a Medical Information Database
accessible to life insurance companies for the purpose of enhancing risk assessment and preventing fraud. Once uploaded, all life insurance companies will have limited access to
our information in order to protect our right to privacy in accordance with law. A copy of circular Letter No. 2016-54 may be accessed at the Insurance Commission’s website at
www.insurance.gov.ph

6. I will indemnify Pru Life UK and hold it free and harmless for any damages incurred by Pru Life UK as a result of any claim filed by any of the data subjects in relation to a breach of
any of the warranties above, or for any damages arising from any misrepresentation made in this Application or from any material breach of its provisions.

Signature over printed name of LIFE INSURED Signature over printed name of PARENT/GUARDIAN

Signature over printed name of POLICYOWNER

PLACE OF SIGNING DATE OF SIGNING (mm/dd/yyyy)

Signature over printed name of AGENT

AUTHORIZATION TO FURNISH MEDICAL INFORMATION

This form should be completed and signed.

Pru Life UK is considering an application for insurance on my life and I hereby authorize YOU* or any physician, surgeon, or other person in your or their employ or who you or
they are connected with, in any way, or any hospital or other entity, to give Pru Life UK or its authorized medical doctor or representative, any information which may be desired
and which was acquired while attending to me in a professional capacity. A photographic copy of this authorization shall be as valid as the original. This authorization is in
connection with my application for insurance only.

Signature over printed name of LIFE INSURED DATE OF SIGNING (mm/dd/yyyy)

Signature over printed name of POLICYOWNER

*YOU refers to the person/party holding or possessing this AUTHORIZATION TO FURNISH MEDICAL INFORMATION.

PAGE 7
REPLACEMENT NOTIFICATION

REMINDERS: It is usually disadvantageous to REPLACE existing life insurance policy/ies with a new one. Some disadvantages are: (a) you may not be insurable under standard terms;
(b) you may have to pay higher premiums in view of higher age; or (c) you may lose financial benefits accumulated over the years. Please note that in your own interest, we advise that
you consult your present insurer before making a final decision. Hear from both sides and make a careful comparison. You can then be sure that you are making a final decision that is
in your best interest.

FULL NAME (Surname, given name, middle name) DATE OF BIRTH (mm/dd/yyyy)

ADDRESS (Number, street, municipality/city, province) COUNTRY

NAME OF APPLICANT IF OTHER THAN THE LIFE INSURED (Surname, given name, middle name)

EXISTING POLICIES TO BE REPLACED

INSURED’S NAME (As it appears in the Policy) COMPANY NAME POLICY NUMBER

In connection with my decision to purchase a product from Pru Life Insurance Corporation of U.K. (”Pru Life UK”), I hereby certify the following:
1) My purchase of the (name of product) is a replacement for my existing Policy/ies with Pru Life UK and/or with another insurance company.

2) My agent has disclosed to me the fees and charges that I will bear in switching from my original Policy/ies to the (name of product)
(”the Replacement Policy”). I understand that the fees and charges would include all fees associated with the disposal of or reduction in coverage or interests under my original Policy/ies and/or
fees incurred during the purchase of or increase in coverage or interests under the Replacement Policy.
3) My agent has advised me of the disadvantages (i.e. loss of financial benefits, higher premium, non-insurability, etc.) that I will or may suffer (temporarily or otherwise) as a result of switching from my
original Policy/ies to the Replacement Policy.

Signature over printed name of POLICYOWNER DATE OF SIGNING (mm/dd/yyyy)

AGENT’S REPORT AND DECLARATIONS (FOR AGENT’S USE ONLY)

Please answer all questions in full. Life Insured Policyowner

1) a. How long have you known the Life Insured or Policyowner?

Number of years Number of years

b. Are you related to the Life Insured or Policyowner? (If yes, please state Yes No Yes No
relationship)

2) Is the Life Insured or Policyowner a fellow active agent or a spouse/child of Yes No Yes No
a fellow agent? (If yes, please state relationship)

3) If the Life Insured or Policyowner is a married person, what amount of life

insurance is now in force on his/her spouse in all companies? State "None" if none.

4) Describe any distinct or visible mark on the Life Insured or Policyowner.

5) Do you know anything about the Life Insured or Policyowner’s present physical Yes No Yes No
condition, morals, association, occupation, or habits which would help facilitate
the underwriting of this application? (If yes, provide details)

6) Life Insured or Policyowner was/will be examined by Dr. on (mm/dd/yyyy)

7) Has there been or will there be any change in any existing insurance in force on
the life of the Life Insured? (If yes, provide details) Yes No

8) Will premiums for the insurance be paid by a policy loan or withdrawal from
any existing policy? (If yes, provide details) Yes No

9) I confirm that the Policyowner and Life Insured have filled out and signed
the Application Form in my presence. Yes No

10) Other details/additional remarks

I hereby represent that all of the above statements and answers to all the above questions are complete and true.

Signature over printed name of AGENT DATE OF SIGNING (mm/dd/yyyy)

PAGE 8