Individual Application Form for Group Life Insurance

AZANZA ZIA MAUSISA

Applicant:
Last Name First Name Middle Name
Address:
28 CAPOAS STREET MASAMBONG QUEZON CITY
NA Office:
NA Mobile: 09755720234 Email:
CHARLENE.MAUSISA@GMAIL.COM
Contact Details: Home:
06/24/2021 MANILA CITY 0 FEMALE 70.2CM 7.4KG
Date of Birth: Place of Birth Age: Sex: Height: Weight:
Nationality: FILIPINO Civil Status : SINGLE Occupation: NA
Employer: NA Place of Work: NA
Policyholder: NA

Name of Beneficiary Date of Birth Relationship

CHARLENE AZANZA 05/10/1994 MOTHER
NOLI AZANZA III 12/14/1991 FATHER

For Credit Life Insurance Only:

Principal
Loan Amount: Loan Term: Co-Borrower
Account Officer: Referred by:

Details of “Yes” answers

HEALTH QUESTIONS ABOUT THE APPLICANT: Yes No (Please indicate question number.
Use back page, if necessary)

1. Any weight change (lost/gained) of more than 5 lbs. during the last 5 months?
If so, by how many pounds and why?
2. Have you ever suffered from or sought medical treatment for:
a. stroke, epilepsy, fainting attacks or any disorder of mental or nervous system?
b. asthma, bronchitis or any lung problem?
c. chest pain, numbness or weakness of extremities or any heart disorder?
d. hyperacidity, ulcer, chronic or recurrent diarrhea, or any other disorder of the digestive
system?
e. diabetes, thyroid and complications to the eyes, kidney, liver and heart?
f. kidney diseases or urinary system disorders such as, blood in the urine or kidney stones?
g. rheumatic fever, arthritis, gout or any joint or bone disorders?
h. cancer, tumor, enlarged gland or blood disorders?
i. unexplained recurrent or persistent fever or skin disorder?
j. any sexually-transmitted disease (such as syphilis or gonorrhea) or viral disease
(e.g. hepatitis B or AIDS)?
k any other illness, injury, disability not mentioned above?
3. Have you ever been diagnosed as suffering from hypertension? Have you ever been
prescribed drugs for this condition?
4. Have you ever undergone any surgical operations or invasive procedures for the last 2
years?
5. Have you ever undergone laboratory test or other diagnostic examinations?
6. Any hospital confinement or surgical procedure being contemplated?
7. Have you ever received treatment with any blood products or undergone blood transfusion?
8. Any other disease or complaint not mentioned above?
9. Except as prescribed by a physician, have you ever used shabu, cocaine, heroin, marijuana
or other narcotics?
10. Do you smoke or have you ever smoked more than 10 cigarettes per day?
11. Do you take or have you ever taken more than six units of alcohol per day
(1 unit = 1/2 pint beer/lager, 1 standard glass of wine, 1 pub measure of spirit)?
12. Are you currently taking medications, or are you under medical care of any kind?
13. For females:
Are you pregnant?
Any complications with pregnancy?
14. Do you have any other application for or reinstatement of life insurance pending?
If yes, give details.
With BDO Life Assurance Company, Inc. P
With other companies P

DISCLOSURE: In accordance with the Insurance Commission’s Circular Letter No. 2616-54, your 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 only have limited access to your
information in order to protect your 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
I, the above-named Applicant, declare that to the best of my knowledge and belief, the above answers and statements are true, complete and correctly recorded; and agree that this
application, if approved, with the answers given in any other declaration which may be required by BDOLAC and which relates to the insurability of the applicant or to a change in
insurance coverage, shall be the basis for delivery, change or reinstatement of insurance coverage.
I agree that:
1. BDOLAC shall incur no liability by reason of this application or by any reason of any cash paid or settlement made in connection therewith, until this application has been approved
by BDOLAC while I am alive and actively at work or actively engaged in the exercise of my occupation with no change having taken place my insurability subsequent to the date
of this application;
2. All materials facts, being facts which might influence the assessment of this Application, have been truthfully, completely and correctly disclosed in this Application and/or any
other declaration which may be required by BDOLAC.
3. The validity of insurance on any insured-member/debtor shall not be contested, except for non-payment of premiums, after his insurance has been in force for two years (2) years
during his lifetime; or
4. BDOLAC reserves the right to deny claims on the basis of gross fraud or valid grounds recognized under the law.
QUEZON CITY APRIL 03, 2022
Signed at _____________________________________________________________________ on ___________________________________

ZIA AZANZA CHARLENE AZANZA

Signature Over Printed Name of Applicant Signature Over Printed Name Of Witness

BDO Life Assurance Company, Inc.

BDO Corporate Center, 7899 Makati Avenue, Makati City, Metro Manila, Philippines
Customer Care Hotline: (632) 8885-4110 | E-mail: info@bdolife.com.ph l www.bdo.com.ph/bdolife
Form No. GLA Ind-A