Policy Number

510 - 8940239

Application Number R 27565-201804240642-2-02

Traditional Variable

Application for Life Insurance

Accomplish the details and put “N/A” if not applicable. Print legibly using BLACK FOR OFFICE USE ONLY
INK. Any erasure should be countersigned by the Owner. This form must be filled out
by the Owner or by a person acting under the Owner’s direction and authority. Date Received:
Time Received:
Important Notes: Receiving
Dept./Office:
1. An Insurance is a contract of utmost good faith and the Proposed
Insured/Proposed Owner is required to disclose ALL material facts to the insurer.
All answers to the questions stipulated in this questionnaire are the basis of and
are an inseparable part of the insurance policy. In case of doubt as to whether a
fact is material or not, the fact should be disclosed.
2. Please do not sign on a blank form.
3. Please shade the circle to indicate your choice(s).

1. DETAILS OF THE PROPOSED INSURED

LAST NAME
Notes
ELAN

FIRST NAME Please accomplish as

well the “Proposed
HYDOE JAMES Owner Details” section
at the back page if the
MIDDLE NAME Proposed Owner is
different from the
BAGON Proposed Insured.

WEIGHT (lbs.) (kg.)

DATE OF BIRTH(YYYY/MM/DD) PLACE OF BIRTH SEX CIVIL STATUS
154

Male Single Married HEIGHT (ft.&in.) (cm)

1992/10/13 SOUTH COTABATO
Female Widow Divorced/Annulled 5' 5''

OCCUPATION NATIONALITY IDENTITY NO. (TIN/SSS/GSIS)

Seaman - Non-Officers - Able-Body Philippines TIN: 468-896-465

Residence Address
should be a Philippine
IF WORKING ABROAD, STATE THE COUNTRY Address (in reference to
RESIDENCE ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE Cross-Border Rule)

Residence Address
PUROK TALISAY BRGY TUYAN MALAPATAN SARANGANI PROVINCE 9516 shall be used as default
mailing address
BUSINESS ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE

Unless you are a bank

GRACE MARINE & SHIPPING CORP. SUITE 200A&B ERMITA CNTR BLDG ERMITA MANILA METRO MANILA 1000 employee, Bank
address and contact
PREFERRED MAILING ADDRESS (Select One) Residence Business information should not
be used
CONTACT NUMBERS (Pls. provide at least two)

HOME PHONE NUMBER MOBILE NUMBER (Mandatory)

0 639270772550

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

6325267968 HYDOEJAMESELAM@YAHOO.COM

SOURCE OF FUNDS/MONTHLY INCOME

Answer this question
Salaries/Php 80000.00 Income from business/Php Savings only if Proposed Insured
is the same as the
Maturing Investment/Php Others Proposed Owner

IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX RESIDENT Yes No

Application For Life Insurance Application Number R 27565-201804240642-2-02

Application For Life Insurance Application Number R 27565-201804240642-2-02

2. DETAILS OF PROPOSED OWNER (If different from Proposed Insured)

LAST NAME
Notes:

FIRST NAME
Accomplish only if
Proposed Owner is
different from Proposed
MIDDLE NAME
Insured.

WEIGHT (lbs.) (kg.)

DATE OF BIRTH ( YYYY/MM/DD) PLACE OF BIRTH SEX CIVIL STATUS

Male Single Married HEIGHT (cm)

(ft.&in.)
Residence Address
Female Widow Divorced/Annulled should
be a Philippine Address
(in reference to
OCCUPATION NATIONALITY IDENTITY NO. (TIN/SSS/GSIS) Cross-Border Rule)

Residence Address
shall
be used as default
IF WORKING ABROAD, STATE THE COUNTRY
mailing address
RESIDENCE ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE

BUSINESS ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE

The Contingent Owner

will automatically
become the new Owner
PREFERRED MAILING ADDRESS (Select One) Residence Business
of this policy in the
event that the Owner
CONTACT NUMBERS (Pls. provide at least two) predeceases the
Insured while this Policy
HOME PHONE NUMBER MOBILE NUMBER (Mandatory) is in force. If the owner
has not appointed a
Contingent Owner, the
Insured shall
BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory) automatically become
the new Owner of this
Policy in the event that
the Owner predeceases
the Insured while the
policy is in force.
RELATIONSHIP OF PROPOSED CONTINGENT OWNER UPON DEATH RELATIONSHIP OF CONTINGENT OWNER Designation of a minor
OWNER TO THE PROPOSED INSURED OF OWNER TO PROPOSED INSURED as Contingent Owner is
discouraged.

SOURCE OF FUNDS/MONTHLY INCOME

Beneficial Owner refers
Salaries/Php Income from business/Php Savings/Php to the owner/controller
Maturing Investment/Php Others of the policy owner as
well as to the
beneficiary to the policy
IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX RESIDENT? Yes No contract. It also refers
to a natural person who
BENEFICIAL OWNER (if any) ultimately owns or
controls the account
and/or the person on
whose behalf a
transaction or activity is
Full name, Present address, Date and place of birth, Nature of work, Source of funds being conducted. It also
includes those persons
3. BENEFICIARY DESIGNATION who has ultimate
effective control over a
*Unless otherwise indicated, Beneficiaries should be specifically named & shall be deemed primary revocable. If the Beneficiary is not changed during the legal person or
lifetime of the Insured, the designation shall be deemed irrevocable. arrangement.
If you designate irrevocable Beneficiaries, you will need the consent of all such Beneficiaries for any and all after-sales transactions. To designate
irrevocable Beneficiaries from among those listed below, write down the names of irrevocable Beneficiaries on the space on Page 4, No. 12 Home Office
Endorsement and Special Instructions.
Surviving Beneficiaries
in the same
TYPE OF
PRESENT PLACE OF DATE OF NATURE OF
RELATIONSHIP
BENEFIT BENEFICIARY classification will
NAME TO PROPOSED
ADDRESS BIRTH BIRTH WORK
INSURED
% equally share in the
Primary Secondary benefits.
PUROK TALISAY BRGY TUYAN MALAPATAN SOUTH Designation of a minor
ELAN, AVELINA BAGON 12/24/1972 Office Parent 50
SARANGANI PROVINCE COTABATO
as Irrevocable
beneficiary is
ELAN, HYBAR PUROK TALISAY BRGY TUYAN MALAPATAN SARANGANI House Wife,
MANDANGIN SARANGANI PROVINCE PROVINCE
6/5/1970
House Husband
Parent 50 discouraged.

Secondary Beneficiaries
are entitled to the
benefits if no Primary
Beneficiary survives
Application For Life Insurance Application Number R 27565-201804240642-2-02

4. BASIC PLAN DETAILS

PREMIUM TYPE CURRENCY BASIC SUM INSURED SINGLE PREMIUM

Regular Pay Single Pay Peso Dollar 1,500,000.00 Notes

PLAN NAME PAYMENT TERM, If applicable YEARS TO MATURE, If applicable

Single Premium refers
Life BasiX Level Death Benefit
to a single one-off
payment that covers
PURPOSE OF THE INSURANCE APPLIED FOR: the entire cost of
the Policy.
Income protection Retirement planning Business continuation Keyman insurance
Children's protection Education funding Outstanding mortgage loan Estate planning (Beneficiaries are preferably "irrevocable")
Savings Others

5. SUPPLEMENT DETAILS

Secure (AD&D) Shield (CI) Protector (Term)

SUM INSURED SUM INSURED SUM INSURED Selection of “Waiver of

Premium” or “Payor’s
Clause” as policy
supplement applies
to the basic and
YRT 20YRT UP TO AGE 55 YRT 20YRT UP TO AGE 55 YRT 5YRT 10YRT supplement riders
where it is applicable
5 Pay 10 Pay 20YRT UP TO AGE 55
5 Pay 5 Pay 10 Pay
10 Pay 20 Pay
20 Pay UP TO AGE 55

Waiver of Premium Care (Hospital Income) YRT 20YRT UP TO AGE 55

Economy Superior Economy Superior Premier

Payor's Clause Regular Premier Applicable only for term
products with conversion
provisions.
Others Rider Name Rider Sum Insured

Rider Name Rider Sum Insured

6. CONVERSION OF TERM INSURANCE

Billing cycle: policies with
* For Individual, Basic Term or Term rider plans 1-15 as Effective Date
Policy No*./Certificate No**.
** For Group Term plans shall
be charged every 5th of
the
month while those with
7. PAYMENT INSTRUCTIONS 16-28 as Effective Date
shall be charged every
20th
MODE OF PAYMENT METHOD OF PAYMENT of the month. For rejected
billings due to insufficient
balance, we will initiate
Annual Semi-annual Auto-Debit Arrangement (ADA) Credit Card rebilling efforts in an
objective to keep your
Quarterly Monthly Post Dated Check (PDC) Cash Others
policy in-force.
:
Policies with IIE feature
and
enrolled in ADA/CC
8. DIVIDENDS/ENDOWMENTS AND PREMIUM DEFAULT OPTIONS (for traditional products only) will automatically be
charged with the
applicable
* DIVIDEND/ENDOWMENTS OPTIONS ** PREMIUM OPTION IIE premium on the 2nd
policy year.
Accumulate with Interest Extended Term Insurance (ETI)
Requests for cancellation
Apply to premiums Reduced Paid Up (RPU) of ADA/CC payments
should be submitted 30
Pay in cash Automatic Premium Loan (APL) days prior to the
scheduled debit/ charge
date.
* By default, if no Dividend/Endowment Options is ** By default, if no Premium Option is selected, below will
selected, below will apply: Accumulate with Interest apply: ETI – for standard cases; RPU – for substandard Requests for PDC pull-out
cases
should be received at
least
5 working days before the
9. DETAILS FOR VARIABLE INSURANCE check maturity date.

TOP-UP OPTIONS, If applicable DEATH BENEFIT OPTIONS, If applicable

Regular Annual Top-Up

Level Increasing
Lump Sum Top-up Amount

Fund Name % ALLOCATION Fund Name % ALLOCATION

1. Opportunity Fund 50 5. All fund allocations
should total to 100%
2. Chinese Tycoon Fund 50 6.

3. 7.

4. 8.
Application For Life Insurance Application Number R 27565-201804240642-2-02

10. DECLARATION OF PROPOSED INSURED and OWNER (if Payor's Clause is applied for)

Proposed Insured Proposed Owner If “Yes”, please

(Owner to answer if payor’s indicate details
clause is applied for)
1. Do you smoke cigarettes/cigars? (If yes, indicate no. of sticks/day
Yes No Yes No PI O
& no. of years)
no. of sticks/day
months/years

2. In the last 2 years, have you:

Yes No Yes No
a. Consulted a medical doctor or been referred for tests or
investigation or had any medical test/s

b. Been diagnosed, or received treatment, medication or

advice pertaining to unexplained weightloss, high
Yes No Yes No
blood, heart or lung disease, diabetes, tumor or cancer,
mental or neurologic dysfunction, liver disease, or any
other ailment with or without physical impairment?

3. Have you had at least 2 immediate family members (parent or

Yes No Yes No
siblings) who were diagnosed or died of hypertension, diabetes,
heart or kidney disease, mental illness or cancer or any diseases
not mentioned above prior to age 50?

4. Including this new application, is your total insurance cover above

Yes No Yes No
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,

Yes No Yes No
bungee jumping, motor racing or hazardous sports or activities for
more than 3x?

6. Are you and/or your immediate family member entrusted with

Yes No Yes No Proposed Insured Proposed Owner
appointive or elective position in the Philippines or in a foreign Position/Public Office
Position/Public Office
state, a senior politician, judicial or military official, senior
executive of government or state-owned or controlled
corporations or political party official?

7. Have your been involved or included in any lawsuit or court

Yes No Yes No If yes, please state reason (indicate the nature
litigation? of case, involvement and status)
Plaintiff/Complainant
Defendant/Accused
Status:

8. For Female Applicant Only Yes No Yes No If yes, how many months?
Are you currently pregnant? Any complications?

9. If Proposed Insured is juvenile

a. How many siblings does the child have?
b. Are all siblings insured? Yes, how much? No, please specify reason

Disclosure: In accordance with the Insurance Commision’s Circular Letter No. 2016-54, 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.

11. REPLACEMENT OF EXISTING LIFE INSURANCE POLICIES

Replacing an existing life insurance with a new one is in most cases disadvantageous as you might be confronted with a loss of financial
benefits or higher premiums in the new plan. Before you decide to replace a policy, ensure that you have full information of both policies.

Is this Policy replacing another policy with AXA or any other insurance company? Yes No

12. HOME OFFICE ENDORSEMENT AND SPECIAL INSTRUCTIONS

13. DECLARATIONS AND AGREEMENT

I/WE UNDERSTAND, DECLARE AND AGREE THAT:

1. Before signing this Application, I/we have read the same carefully and the questions were fully explained to me/us in a
language/dialect which I/we understand.
2. The answers or statements made in this Application and those that I/we made in the Full Medical Report and any other document
attached thereto, are complete, true and correctly recorded and shall form part of and be the basis of the insurance contract herein
applied for. Failure to make a full disclosure renders the contract voidable.
3. I/We understand that the designated Contingent Owner (if any) will automatically become the new Owner of this policy or in the event
that I/we have not designated a Contingent Owner, I/we understand that the Insured shall automatically become the new Owner of
the Policy in the event that the Owner predeceases the Insured while the Policy is inforce.
Application For Life Insurance Application Number R 27565-201804240642-2-02

4. I/We declare that I/we am/are aware of the consequences of a minor beneficiary designation as follows: (a) that a minor, if designated
irrevocable, is still unable to give a valid consent to any transaction on the policy; where such consent is required, the minor would need
representation by a guardian appointed by the court when transactions like policy loan, surrender, changes in benefit, etc. are applied for
under the policy: (b) when a death claim is filed under the policy, whether the minor is a revocable or irrevocable beneficiary, a court
appointed guardian and guardian’s bond may be required.
5. All the information I/we provided on this application from are to the best of my knowledge true and correct.
6. Any of my/our personal information collected or held by AXA Philippines (whether contained in the application/s or otherwise), may be used
in connection with matching for whatever purpose with such other personal information and/or may be used, stored, disclosed, transferred
(whether within or outside the Philippines) to such persons as AXA Philippines may consider necessary, including without limitation but not
limited to any of its affiliated or related companies, or any individuals/organizations/corporations/entities associated with AXA Philippines:
a. to process and deal with my application/policy;
b. to provide all services related to my application/policy, to promote other products/services by AXA Philippines and its affiliated or
related companies/entities, and to process my information for product development and for marketing purposes;
c. to communicate with me for any purpose and/or to comply with the laws of any applicable jurisdiction.
7. I/We have the right to request access to and correct any of my personal information held by AXA Philippines. I/We understand that such
request may be made in writing and submitted to the Policy Services Unit of AXA Philippines.
8. I/We understand that AXA shall use my/our personal information to evaluate and assess my/our application and need for life insurance and
investments, as well as to service any of my/our policies and needs including the evaluation of any future claims. I/We also authorize AXA
to disclose to any person or entities providing services on AXA’s behalf consistent with the purpose for which the information was obtained.
9. I understand that notices related to my policy may be sent to me through mail, email or SMS in the address/number I provided above.
10. I/We declare that I/we have informed AXA of all my/our citizenships, residencies and tax residencies, and provided AXA with my/our
taxpayer identification number(s). I/We agree to promptly update AXA of any changes to said information. I/We authorize AXA to disclose
my/our personal information to any government or tax authority (within or outside the Philippines) for the purposes of ensuring AXA's
compliance with applicable laws and regulations. I/We agree that AXA shall have the right to: (a) require the claimant(s) and/or payee(s) of
the Policy to provide AXA with their above-mentioned personal information and/or sign such documents as AXA may reasonably require;
(b) and disclose said personal information to any government or tax authority (whether within or out of the Philippines) for the purposes of
AXA's compliance with applicable laws and regulations. If I/we fail to any of the above-mentioned acts, I/we agree that AXA may provide
my/our personal information to such government or taxation authority(ies) to comply with the applicable laws and regulations.
11. The amounts invested have been declared to relevant tax authorities and none of it was derived, directly or indirectly, from illegal activities
or sources and/or tax evasion. If required by the proper tax and/or other governmental authorities, AXA Philippines may, in its discretion,
disclose certain information about me/us or about my policy.
12. I/We hereby authorize any person, physician, clinic, hospital, insurance company, or other organization, insurance association, institution,
that has any record or knowledge of my/our health and/or financial information to disclose or release to AXA Philippines or its authorized
companies and their affiliates any medical information sharing facility of the insurance industry, or any government agency requiring such,
for any legitimate purpose, including underwriting and administration of insurance coverage and claims.
13. I/We authorize AXA Philippines to request and obtain from third parties, whether government agencies or private entities, any information
concerning me/us relevant to this application, including medical or financial information.
14. In case of apparent errors or omissions in this Application, or if AXA Philippines is unwilling to issue the policy applied for, AXA Philippines
may amend this Application by noting the change in the space entitled “Home Office Endorsement” and issue the policy on the basis of
such amended Application, and acceptance of such policy by me will ratify such amendment.
15. There shall be no contract of insurance unless and until a policy is issued on this Application and the full first premium of the basic life
insurance and any special benefit applied for, according to the mode of payment specified in answer to Part 7, is actually paid during the
lifetime and good health of the Proposed Insured.
16. I/We have read and fully understood the Life Insurance Proposal (or the illustration of benefits) for the policy applied for.

17. An electronic copy of this application (i.e. scanned or faxed) shall be binding to me/us and shall be considered as good as the original
manually signed document. I/We will inform the Company of any discrepancy between the electronic copy and the original as soon as
possible, and I/we understand that absent any correction within a reasonable period, the Company is entitled to rely on the electronic copy
exclusively.
18. I/We understand that Inflation Index Endorsement (IIE), if included in the Life Insurance Proposal, will be applied at each Policy
Anniversary. I further understand that IIE means that with no further proof of insurability and with a minimal additional premium, my
insurance protection will be increased to ensure that the basic sum insured will be maintained against inflation. I/ We also understand that I
can choose not to avail of IIE by informing the Company via email, call or advise through my/our distributor.
19. Other agreements pertaining to Variable Life Insurance products:
a. My/Our Fund Allocation instruction, if applicable, is based on my/our own judgment and I/we have not relied on any advice provided by
the Advisor/FE;
b. I/We am/are fully aware that, if applicable, relevant policy charges, e.g. bid-offer spread, premium charge, asset management charge,
will be imposed on the policy that will be issued;
c. I/We fully understand that a variable life insurance product involves risk. Value of units in Investment Funds may rise or fall. The
benefits payable under such product are linked to the performance of the Investment Funds according to my Fund Allocation
Instruction;
d. I/We fully understand that if this application is cancelled by written notice, signed and sent by me/us directly to and received by the
New Business and Underwriting Department of AXA Philippines before it is approved, I/we can refund all the premium deposits paid
by me/us and received by AXA Philippines. If such notice is received by the New Business and Underwriting Department of AXA
Philippines after the application is approved, the amount of refund shall be equal to the market value of its units including initial
charges; and
Application For Life Insurance Application Number R 27565-201804240642-2-02

e. I/We understand that I have the right to cancel the policy to be issued during the cooling-off period provided therein and obtain a refund
equal to the market value of units including the initial charges thereof by giving a written notice and returning the policy. Such notice must
be signed and sent by me/us directly to and received by Customer Experience of AXA Philippines within 15 days from my/our receipt of the
policy.
20. In the event of the Insured’s death prior to his/her attaining the age of four (4) years and six (6) months:
a. the amount payable under the Policy shall be in accordance with the following schedule:
Age at Death Amount Payable Death Benefit Payable
(nearest birthday) (Variable Life Policy) (Traditional Life Policy)

Less than 6 months 50% of the Sum Insured, or the Account Value, whichever is higher 50% of the Sum Insured
1 year 60% of the Sum Insured, or the Account Value, whichever is higher 60% of the Sum Insured
2 years 70% of the Sum Insured, or the Account Value, whichever is higher 70% of the Sum Insured
3 years 80% of the Sum Insured, or the Account Value, whichever is higher 80% of the Sum Insured
4 years 90% of the Sum Insured, or the Account Value, whichever is higher 90% of the Sum Insured

b. If the Guaranteed Insurability Endorsement is attached to the Policy, the amount payable shall be the Death Benefit applicable in the
Guaranteed Insurability Endorsement, provided that the Insured’s death is due to causes other than a Covered Injury as defined in such
endorsement.
c. The total amount of Death Benefits payable from the Policy and other in force policies and/or supplementary contracts issued by AXA
Philippines shall be subject to the maximum aggregate juvenile limit set by AXA Philippines and prevailing at the time the Policy was
issued. Should the total Death Benefits payable from the Policy and from all other in force policies and supplementary contracts issued by
AXA Philippines covering the Insured exceed the limit, then the benefit under the last policy(ies) or supplementary contract(s) which gave
rise to the excess shall be correspondingly reduced and a proportionate refund of the Premiums paid on such portion of the benefit shall be
made to the Owner, without interest.
d. Benefits will still be subject to the Minimum Death Benefit as stated on the variable life insurance contract which will be issued to You. For
a single premium variable life insurance contract, this is equal to 125% of Single Premium paid, plus 125% of each subsequent top-up
premiums, if any, less 125% of each partial withdrawal, if any. Additionally, for a regular-pay variable life insurance contract, this is equal to
500% of the annual premium paid, plus 125% of each subsequent top-up premiums, if any, less 125% of each partial withdrawal, if any.

14. REQUEST FOR DIRECT CREDIT TO BANK ACCOUNT

I/We, hereby permit AXA Philippines to call me/us to clarify or gain further information regarding any matter pertaining to the assessment and
processing of my/our application for life insurance.

I / We understand that:

• I am/we are required to be truthful to the best of my/our knowledge

• The call is recorded and will take a few minutes of my /our time
• My/our answers will be binding and shall form part of the basis of my/our application for life insurance
• The result of the call will be documented and a copy of which, shall be attached to the policy contract.

I / We may be contacted at any of the contact numbers declared in the application form.

During office hours (8 am-5 pm) Others, please specify

15. REQUEST FOR DIRECT CREDIT TO BANK ACCOUNT

Policy No.: Account Type: Bank Name:

Peso Account Dollar Account Metrobank Others

Branch Name Swift Code (for Non-Metrobank) Account Number of payee:

Account Name of payee: Relationship to owner

Spouse Child Parent Sibling

1. I declare that the proceeds of this application/policy once deposited to the account aforementioned shall be equivalent to payment
to me directly of the same and I shall render AXA Philippines, its successors-in-interests and assigns, including its directors,
officers, employees and agents, free and harmless from any further claim, demand or action whatsoever, which in law or equity I
ever had, now have, or which I, my successors and assigns hereafter may have under this said application/policy.

2. I declare that in the event the account aforementioned is owned by person other than me, the account owner is my relative and
that I had sought his/her consent to use his/her account to facilitate the payment to me of the proceeds of this application.

3. I understand that should the proceeds be credited to a non-Metrobank account, corresponding fees shall be charged to my
account.
4. I/We, the undersigned, also take full responsibility in the accuracy of the account name and number indicated above. Should
there be any error(s) in the information, I/We understand that this will result to delays in the crediting of the policy proceeds and
I/We shall bear the consequences.

5. Before signing this declarations and agreements, I have read and understood all declarations and agreements which are hereby
given and made willingly and voluntarily and with full knowledge of my rights under the law.
Application For Life Insurance Application Number R 27565-201804240642-2-02

**PLEASE DO NOT SIGN ON A BLANK FORM

Date of Signing: Place of Signing:

HYDOE JAMES ELAN

Signature (Proposed Insured) Signature (Proposed Owner)

**(If this form was filled out by an Advisor/FE) I certify that I have acted under the direction and authority of the Owner and
that the Owner and/or Proposed Insured signed this Application Form in my presence.

Name of Advisor/FE: MARCOS, JAYSON EBOJO Name of Advisor/FE:

Code: Code:

42621 4 27565

Signature: Signature:

16. DISTRIBUTOR'S DECLARATION

I ensure that I, as the distributor, have completed all relevant and necessary information to assist the Company in
assessing the application.
I further declare that:

1. The information provided in the application form are accurate and complete;
2. I shall make known to the Company any and all factors which, if known to the Company, may result in an applicant
receiving rated or no coverage at all;
3. Any additional information that shall be required by the Company in order to determine any particular application shall
be provided on a timely basis; and
4. I have physically seen the persons who are being insured by the Policy Owner.

Name of Advisor/FE: MARCOS, JAYSON EBOJO Signature of Advisor/FE

Application For Life Insurance Application Number R 27565-201804240642-2-02

17. CREDIT CARD AUTHORIZATION/AUTO-CHARGE ENROLLMENT

Please refer to the back page for the Declaration and Reminders of this application form
Currency: PHP USD | ONE-TIME CHARGE RECURRING PREMIUMS* Date
*Succeeding premiums due will be automatically charged to the enrolled card no.

CREDIT CARD ENROLLMENT FORM

Account Type: Visa Mastercard Month Year

Credit Card Expiry Date /

Number

Credit Card Company: Billing Address:

Cardholder's Name:

(Last Name) (First Name) (Middle Name)

Cardholder's Birthday: Amount of Premium:

Mother's Maiden Name: Name of Insured:

Contact Number(s)
of Cardholder: Policy Number:

Relationship of cardholder to Owner of policy

Visa Spouse Sibling (To be signed by the Policy Owner if different from Cardholder)

Signature over printed name of Cardholder Signature over printed name of Policy Owner

I authorize AXA Philippines to charge my premiums to my credit card account as indicated in the Credit Card
EnrollmentForm. I understand that the Policy will not be inforce until I have made the first premium payment. I hereby
authorize AXA Philippines to initiate and the card company to effect, charge entries to my account for payment of
premiums due from the above-captioned policy. The Bank/card company is hereby authorized to disclose to AXA
Philippines such information as may be necessary to implement this payment arrangement. I understand that only the
account’s cleared and available balance shall be charged. In the event that there is insufficient balance, AXA Philippines
may initiate debit charges against my credit card account as it deems necessary and at its sole discretion. If no payment
was charged from the account due to insufficient balance, termination of account or other reason as advised by the card
company, AXA Philippines shall not consider the premium due from the above policy to have been paid and AXA
Philippines shall have the recourse to collect directly from me or terminate my policy should I fail to settle the premium
within the grace period. I further understand and agree that constant unsuccessful debiting of my account due to
insufficiency of funds shall be a valid ground for the immediate cancellation of this payment arrangement even without
prior notice.

I also understand that I may withdraw from this premium payment arrangement effective 30 days after receipt by AXA
Philippines of a written notice of withdrawal.

I agree to promptly inform AXA Philippines of any changes in my credit card information, e.g. new card number, new
expiry date, etc. I understand that AXA Philippines will effect the changes 30 days after my notice.

Reminders
1. Credit Card Number must be 16 digits.
2. Official Receipt date for succeeding payments shall be equal to the date when electronic payment posting is
done,usually within 3 days from charge date.
3. Billing cycle: policies with 1-15 as Effective Date shall be charged every 5th of the month while those with 16-28
as Effective Date, shall be charged every 20th of the month. If the 5th or 20th falls on a holiday, the debit
transaction will be done on the next banking day.For rejected billings due to insufficient balance, we will initiate
rebilling efforts in an objective to keep your policy inforce.
4. No premium notice shall be issued to policies enrolled in the Auto-charge facility.
Application For Life Insurance Application Number R 27565-201804240642-2-02

Application Number R 27565-201804240642-2-

TEMPORARY LIFE INSURANCE CERTIFICATE
There is temporary insurance on the life to be insured beginning on the date of signing by the Proposed Insured/Owner of the Application form
bearing the same serial number as this certificate, if all the following conditions are met: (1.) The first modal premium has been paid with the
Application for which a Temporary Receipt is issued; (2.) Questions stated on section no. 10 were answered “NO” by the Proposed Insured and (3.) All
other required questions of the Application form are answered completely and truthfully. All conditions under this certificate are subject to the
Provisions of the Policy the Proposed Insured and/or Owner has applied for.

LIMITATION ON AMOUNT OF INSURANCE

The insurance benefit on the death of the life insured pursuant to this certificate is the amount which AXA Philippines would have paid had the Policy
applied for been issued. AXA Philippines shall in no event pay, subject to the imposition of juvenile lien whenever applicable, no more than One
Million Pesos (PhP1,000,000) or the equivalent in US Dollars, based on the prevailing exchange rate at the time of death of the Proposed Insured.
The maximum amount of PhP1,000,000 includes any accidental death benefit, under all Temporary Life Insurance Certificates inforce in respect of
the Proposed Insured. However, if the insurance benefit paid for by the Proposed Insured exceeds the said maximum, the amount of excess
premium, which will be determined proportionately to the Policy applied for, will be refunded. The insurance benefit will be prorated among all the
Temporary Life Insurance Certificates inforce on that Proposed Insured.

TERMINATION OF TEMPORARY LIFE INSURANCE COVERAGE ON THE LIFE INSURED WILL BE THE NEAREST OF THE FOLLOWING:

(a) The date a termination notice is sent by AXA Philippines to the Applicant;
(b) The date the policy is issued as a result of the Application being approved;
(c) The date of termination as requested by the Applicant;
(d) The date of death of the Proposed Insured; and
(e) Sixty (60) days after signing this Application.

SUICIDE: If the life insured dies by suicide, the pertinent provisions of the Insurance Code shall apply. Where no insurance money is payable, the
amount paid with the Application will be refunded. No Advisor/Financial Executive has the authority to modify the terms of this Certificate.

IMPORTANT NOTICE
The Insurance Commission, with offices in Manila, Cebu and Davao, is the government office
in charge of the enforcement of all laws related to insurance and has supervision over insurance
providers and intermediaries. It is ready at all times to assist the general public in matters pertaining to
insurance.
For any inquiries or complaints please contact the Public Assistance and Mediation Division (PAMeD)
of the Insurance Commission at 1071 United Nations Avenue, Manila
with telephone numbers +632-5238461 to 70 and email address pubassist@insurance.gov.ph.
The official website of the Insurance Commission is www.insurance.gov.ph.
 Proposed Insured:
Mr. HYDOE JAMES BAGON ELAN
Age 26, Male, Non-smoker

Policyowner or Payor:
Mr. HYDOE JAMES BAGON ELAN
Age 26, Male

Dear HYDOE JAMES,

Thank you for your interest in AXA products. Life BasiX is a regular-pay variable life insurance product that addresses life's essential
needs for basic protection with opportunities for long-term investment. But unlike most investments, it provides multiple benefits as
follows:

KEY BENEFITS:

1. Guaranteed Death Benefit equivalent to at least 500% of the annual premium if no withdrawal is made.
2. Potential upsides from the portion of the premium placed in bonds, equities and/or money market instruments, depending on your
risk appetite.
3. Guaranteed loyalty bonus as a reward for keeping your investments with AXA.
For a premium of PHP 60,180.00 annually, you get to enjoy the following benefits:
BENEFITS
For You For Your Loved Ones
(Living Benefits) (Death Benefits)

When insured reaches age 65 Upon death of the Insured

Based on (PHP) Based on 8% annual rate (PHP)
4% annual rate of return, Account Value 4,780,152 Age 50 3,312,000
Or 8% annual rate of return, Account Value 12,480,854 Age 60 8,252,109
Age 70 18,694,267
Or 10%annual rate of return, Account Value 20,806,548

Notes:
1. The values above are based on the projected performance of your chosen fund/s. Since the fund performance may vary, the values of your
units are not guaranteed and will depend on the actual investment performance at that given period. The illustrated returns on investments
are based on assumed annual rates of 4%, 8%, and 10%. These rates are for illustration purposes only and do not represent maximum or
minimum return on your fund.
2. If after purchasing the variable life insurance contract, you realize that it does not fit your financial needs, you may return the
contract to AXA Philippines within 15 days from the time you receive it. AXA Philippines will return to you the account value, the
bid-offer spread, and all initial charges.
3. Any withdrawal from the Living Benefit will correspondingly reduce the Death Benefit payable.

This is not a deposit product. Earnings are not assured and principal amount invested is exposed to
risk of loss. This product cannot be sold to you unless its benefits and risks have been thoroughly
explained. If you do not fully understand this product, do not purchase or invest in it.

Page 10 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 2:58:25 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Philippine Peso
for: Mr. HYDOE JAMES BAGON ELAN, 26, Male, Non-smoker

SPECIAL FEATURES

Top-up Subject to the rules set by AXA Philippines from time to time, you have the option to increase the
benefits of your Policy by paying additional premiums on top of your regular premium which will
be used to buy more units on your chosen investment fund(s).
Premium Holiday Premiums are paid throughout the life of your Policy, but you have the option to suspend
payment anytime as long as the Account Value is sufficient to cover these.
Loyalty Bonus As long as your Policy remains in force, a 5% Loyalty Bonus will be paid on the 15th and 25th
year to increase your Account Value. The Bonus will be equal to 5% of the average of the month-
end Account Values for the last 120 months.
Inflation Link You have the option to increase your insurance protection, with no further proof of insurability, at
a minimal cost of insurance deduction on each anniversary of your Policy, before age 60 with the
Inflation Index Endorsement (IIE). This also does not require that you provide further proof of
insurability. The amount by which you can increase your coverage is based on the current
Consumer Price Index subject to a minimum that AXA Philippines may determine from time to
time.

The succeeding pages of this proposal provide more details on the benefits and features of Life BasiX.

Again, thank you for your interest in AXA products. If you have questions, please call me at the number specified below, or call the AXA
Philippines Customer Care Hotline at Tel Nos: (02)5815-292 or (02)3231-292.

MARCOS, JAYSON EBOJO

42621
27565
639999931380

Page 11 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 02:58:25 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Philippine Peso
for: Mr. HYDOE JAMES BAGON ELAN, 26, Male, Non-smoker

Life BasiX is a regular-pay variable life insurance product where a portion of the premiums, net of the company’s charges, is invested
into your choice of funds. Subject to the rules set by AXA Philippines from time to time, you can increase your investment anytime by
paying top-up premiums, but the value of the funds (and your policy benefits) may go up or down depending on market conditions. The
death benefit option you have elected is Level. The minimum Death Benefit in this proposal is PHP 300,9001.
Below are important details of the proposal along with how your investment will be allocated between the available funds. You may
change this allocation anytime depending on your investment goals and/or risk appetite.

Basic Plan and Supplements Cover up to Age Sum Insured (PHP) Annual Premium (PHP)

Basic
Life BasiX 100 1,500,000 60,180.00
Total² 60,180.00

You may also pay your premium in the following modes:

Modes of Payment Modal Premium Fund Name ³ Fund Allocation
(PHP)
Semi-Annual 30,090.00 Opportunity Fund 50%
Quarterly 15,045.00 Chinese Tycoon Fund 50%
Monthly 5,015.04

Notes:
1. This is the minimum Death Benefit at policy inception. The minimum Death Benefit for any policy year is equal to 500% of the annual regular Life Basix premium, plus
125% of each paid top-up premium, if any, less 125% of each partial withdrawal, if any.
2. Premiums for all products are payable up to termination age. For the premium term of the supplement/s, if any, please refer to the supplement definition indicated in
the "Summary of the Riders Attached to this Proposal".
3. See Product Notes for description of the funds.

Page 12 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 02:58:25 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Philippine Peso
for: Mr. HYDOE JAMES BAGON ELAN, 26, Male, Non-smoker

ILLUSTRATION OF BENEFITS

The illustrated benefits of your policy (subject to actual market performance) are shown below.
ILLUSTRATION OF BENEFITS
Total Cumulative Regular
End of 4.00 % Rate of Return 8.00 % Rate of Return 10.00 % Rate of Return
Basic Premium, Rider
Policy
Premiums and Top-up, if
Year Living Benefit Death Benefit Living Benefit Death Benefit Living Benefit Death Benefit
any, Paid
1 60,180 31,704 1,500,000 33,050 1,500,000 33,724 1,500,000
2 120,360 64,775 1,500,000 68,853 1,500,000 70,934 1,500,000
3 180,540 99,289 1,500,000 107,657 1,500,000 112,010 1,500,000
4 240,720 135,296 1,500,000 149,701 1,500,000 157,343 1,500,000
5 300,900 172,878 1,500,000 195,274 1,500,000 207,392 1,500,000
10 601,800 501,256 1,500,000 616,039 1,500,000 683,892 1,500,000
15 902,700 933,721 1,500,000 1,278,513 1,500,000 1,502,796 1,502,796
20 1,203,600 1,443,585 1,500,000 2,233,545 2,233,545 2,797,451 2,797,451
25 1,504,500 2,143,733 2,143,733 3,749,248 3,749,248 5,023,888 5,023,888
30 1,805,400 2,924,389 2,924,389 5,864,673 5,864,673 8,468,205 8,468,205
35 2,106,300 3,874,177 3,874,177 8,972,926 8,972,926 14,015,313 14,015,313
40 2,407,200 5,029,739 5,029,739 13,539,970 13,539,970 22,948,984 22,948,984
45 2,708,100 6,435,657 6,435,657 20,250,456 20,250,456 37,336,752 37,336,752
50 3,009,000 8,146,172 8,146,172 30,110,362 30,110,362 60,508,395 60,508,395
55 3,309,900 10,227,274 10,227,274 44,597,797 44,597,797 97,826,559 97,826,559
60 3,610,800 12,759,253 12,759,253 65,884,594 65,884,594 157,927,834 157,927,834

Age60 2,046,120 3,669,035 3,669,035 8,252,109 8,252,109 12,685,028 12,685,028

Age65 2,347,020 4,780,152 4,780,152 12,480,854 12,480,854 20,806,548 20,806,548
Age70 2,647,920 6,131,996 6,131,996 18,694,267 18,694,267 33,886,336 33,886,336
The rates of return shown above are for illustration purposes and are not based on past performance nor guarantee future performance. The actual
return may differ. The illustrated values are net of premium charges of 35%/35%/35%/35%/35% of the basic premium for the 1st to 5th policy years; all top-ups
shall be subject to a premium charge of 2%; Cost of Insurance has been deducted monthly from the illustrated values as well as Administration Charge amounting
to Php1,200 p.a. The Annual Premiums for any attached Supplement shall be deducted monthly from the illustrated values if the Policy is under Premium Holiday.
An Asset Management Charge of 2% p.a. for Philippine Wealth Bond, Philippine Wealth Balanced and Philippine Wealth Equity Funds and 2.5% p.a. for
Opportunity, Chinese Tycoon and Spanish American Legacy Funds have already been deducted from the illustrated values. The illustrated values are still
subject to a surrender charge for withdrawals (partial or full) transacted up to the 5th policy year. The surrender charge is equal to the amount withdrawn multiplied
by a surrender factor of 100%/100%/25%/10%/5% for the 1st to 5th years respectively.

This illustration shall form part of the insurance contract once the Policy is issued.

Page 13 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 02:58:26 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Philippine Peso
for: Mr. HYDOE JAMES BAGON ELAN, 26, Male, Non-smoker

ILLUSTRATION OF BENEFITS (with Premium Holiday on Year 10)

You can choose to suspend payment for regular premium and top-ups as long as the Account Value of your Policy is sufficient to cover
the charges and pay for the premium of any supplement. This feature is called a Premium Holiday which you can apply for. Note that
under this feature, there is a possibility that your Account Value may be depleted and may result to your policy being terminated.

The following table is an example of the impact of a premium holiday at year 10 and/or withdrawals from the fund assuming different
rates of return. However, note that the rates of return are for illustration purposes only. They are not based on past performance nor
guarantee future returns.

Total Cumulative ILLUSTRATION OF BENEFITS (with Premium Holiday on Year 10)

End of Regular Basic 4.00 % Rate of Return 8.00 % Rate of Return 10.00 % Rate of Return
Policy Premium, Rider
Year Premiums and Top Living Benefit Death Benefit Living Benefit Death Benefit Living Benefit Death Benefit
-up, if any, Paid
1 60,180 31,704 1,500,000 33,050 1,500,000 33,724 1,500,000
2 120,360 64,775 1,500,000 68,853 1,500,000 70,934 1,500,000
3 180,540 99,289 1,500,000 107,657 1,500,000 112,010 1,500,000
4 240,720 135,296 1,500,000 149,701 1,500,000 157,343 1,500,000
5 300,900 172,878 1,500,000 195,274 1,500,000 207,392 1,500,000
10 601,800 501,256 1,500,000 616,039 1,500,000 683,892 1,500,000
15 601,800 602,058 1,500,000 905,557 1,500,000 1,107,536 1,500,000
20 601,800 700,616 1,500,000 1,309,693 1,500,000 1,770,975 1,770,975
25 601,800 850,339 1,500,000 1,979,554 1,979,554 2,932,356 2,932,356
30 601,800 996,823 1,500,000 2,901,273 2,901,273 4,714,872 4,714,872
35 601,800 1,173,698 1,500,000 4,255,581 4,255,581 7,585,631 7,585,631
40 601,800 1,396,279 1,500,000 6,245,503 6,245,503 12,209,017 12,209,017
45 601,800 1,688,701 1,688,701 9,169,352 9,169,352 19,655,026 19,655,026
50 601,800 2,047,923 2,047,923 13,465,444 13,465,444 31,646,899 31,646,899
55 601,800 2,484,972 2,484,972 19,777,814 19,777,814 50,959,931 50,959,931
60 601,800 3,016,709 3,016,709 29,052,756 29,052,756 82,063,761 82,063,761

Age60 601,800 1,135,295 1,500,000 3,941,511 3,941,511 6,897,177 6,897,177

Age65 601,800 1,346,924 1,500,000 5,784,032 5,784,032 11,100,255 11,100,255
Age70 601,800 1,624,930 1,624,930 8,491,299 8,491,299 17,869,355 17,869,355
The rates of return shown above are for illustration purposes and are not based on past performance nor guarantee future performance. The actual
return may differ. The illustrated values are net of premium charges of 35%/35%/35%/35%/35% of the basic premium for the 1st to 5th policy years; all top-ups
shall be subject to a premium charge of 2%; Cost of Insurance has been deducted monthly from the illustrated values as well as Administration Charge amounting
to Php1,200 p.a. The Annual Premiums for any attached Supplement shall be deducted monthly from the illustrated values if the Policy is under Premium Holiday.
An Asset Management Charge of 2% p.a. for Philippine Wealth Bond, Philippine Wealth Balanced and Philippine Wealth Equity Funds and 2.5% p.a. for
Opportunity, Chinese Tycoon and Spanish American Legacy Funds have already been deducted from the illustrated values. The illustrated values are still
subject to a surrender charge for withdrawals (partial or full) transacted up to the 5th policy year. The surrender charge is equal to the amount withdrawn multiplied
by a surrender factor of 100%/100%/25%/10%/5% for the 1st to 5th years respectively.

The contract term is specified in the illustration of benefits in this proposal. Please refer to the assumptions below used in the above
example.
Other Assumptions:
1. This example assumes that all premiums shown in the above table are paid in full when due and as planned with no premium holiday in the first
10 policy years. It assumes the current scale of charges remains unchanged.
2. A loyalty bonus estimated to be 5% of the average Account Value from 6th to 15th policy years on the 15th year, 5% of the average Account
Value from the 16th to 25th policy years on the 25th year is included in this illustration. The bonus will be equal to 5% of the average of the
month-end Account Values over the last 120 months.
3. The proposed policy charges used in this illustration summary are based on the standard risk class without taking into account your own
circumstances (e.g. occupation and health condition, etc). Risk class will be determined according to our underwriting guidelines. The
investment gains/risks associated with this plan are solely to your account.

Page 14 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 02:58:27 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Philippine Peso
for: Mr. HYDOE JAMES BAGON ELAN, 26, Male, Non-smoker

Notes on the illustration of Benefits

1. All payments and benefits shown are in Philippine pesos. Payments are acceptable in policy currency only.
2. AXA Philippines reserves the right to adjust the Basic and Supplement premiums, and any charges in this plan.
3. The quoted values are illustrations only of the key features, benefits and assumptions of the chosen insurance plans. If your
application is accepted, you will receive a policy contract, which will include detailed terms, conditions, and exclusions. A new
Illustration of Benefits will be provided in the contract, which may differ from this proposed illustration.
4. The benefits and premiums of the Index-linked Increase Endorsement, if any, are not included in the summary in the previous page.
5. The benefits are based on the projected performance of your chosen fund/s. Since fund performance may vary, the values of your
units are not guaranteed and will depend on the actual investment performance at that given period. The illustrated returns on
investments are based on assumed annual rates of 4.00%, 8.00%, and 10.00%. These rates are for illustration purposes only and do
not represent maximum or minimum return on your fund value.
6. A bid-offer spread, which is the difference between the bid price and the offer price units, may be determined by AXA Philippines from
time to time. The above illustration is based on a bid-offer spread of 5%.
7. This illustration summary relates to your Life BasiX only, and excludes any Supplements in this proposal. It assumes that all premiums
are paid in full when due and as planned with no premium holiday and the current scale of charges remains unchanged. Any deviation
from this will change the illustrated values accordingly.
8. A loyalty bonus, credited on the 15th and 25th policy years, is included in the illustration. The bonus is estimated to be 5% of the
average of the month-end Account Values over the last 120 months.
9. The proposed policy charges used in this illustration summary are based on the standard risk class without taking into account your
own circumstances (e.g. occupation and health condition, etc). Risk class will be determined according to our underwriting guidelines.
The investment gains/risks associated with this plan are solely to your account.

Product Notes
1. Life Basix is a regular-pay variable life insurance plan. Only the minimum Death Benefit is guaranteed while the Policy is in-force. The
rest of the benefits, namely the partial and full withdrawal values and the actual Death Benefit at time of death, all depend on the
investment experience of separate account(s) linked to the Policy.
Under the INCREASING DEATH BENEFIT OPTION, your beneficiaries will receive the Policy Sum Insured plus the Account Value at time
of death. While under the LEVEL DEATH BENEFIT option, your beneficiaries will receive the Policy Sum Insured less the partial
withdrawals made for the past twelve (12) months, or the Account Value at time of death, whichever is higher.
2. The living benefits shown in the illustration summary are equal to the Account Value of the Policy.
3. The client may choose from the following funds. If client chooses to invest in more than one fund, a minimum allocation of 10% on
one fund is required. The total allocation should always be 100%.
a. Philippine Wealth Bond Fund - This Bond Fund is an actively managed fixed income fund that seeks to capitalize on
capital and income growth through investments in interest-bearing securities issued by the Philippine Government and
money market instruments issued by banks.
b. Philippine Wealth Balanced Fund - This Balanced Fund is designed to achieve long-term growth through both interest
income and capital gains with an emphasis on providing a modest level of risk. It seeks to manage risk by diversifying asset
classes and industry groups through investment in bonds issued by the Philippine government and equities issued by
Philippine corporations comprising the Philippine Stock Exchange Index.
c. Philippine Wealth Equity Fund - This Equity Fund seeks to achieve long-term growth of capital by investing mainly in
equities of Philippine corporations comprising the Philippine Stock Exchange Index. The fund aims to provide access to a
diversified portfolio of equities from different industries.
d. Opportunity Fund - This equity fund aims to achieve long term growth through capital gains and dividends by investing in
equities of Philippine corporations that will provide access to a diversified portfolio of equities from different industries.
e. Chinese Tycoon Fund - This equity fund aims to achieve medium to long term growth through capital gains and dividends
by investing in equities that will provide access to a management themed-portfolio reflective of the Chinese-Filipino
entrepreneurial spirit through strategic investments in Philippine companies from different industries.
f. Spanish American Legacy Fund - This equity fund aims to achieve medium to long term growth through capital gains and
dividends by investing in equities that will provide access to a management themed-portfolio through strategic investments
in Philippine companies from different industries with Spanish/American heritage.
4. The Bid Price of an Investment Fund is the price for cancelling a Unit of the Investment Fund as determined in accordance with the
Valuation provision.
5. The Offer Price of an Investment Fund is the price for creating a Unit of the Investment Fund as determined in accordance with the
Valuation provision.

Page 15 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 02:58:27 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Philippine Peso
for: Mr. HYDOE JAMES BAGON ELAN, 26, Male, Non-smoker

Attached Supplements
Summary of the Riders Attached to this Proposal
1. The Index-linked Increase Endorsement (IIE) allows you to increase your insurance benefits at the rate of inflation with no
additional medical or processing requirements so you can be sure the value of your benefits cope with future costs.

NOTES:
1. The rates shown, if any, are those currently in effect. The rates applicable upon renewal of the Supplement will be those in effect at the date of
renewal.
2. For a detailed description of the Supplements, including exclusions and other provisions, please refer to the policy contract.

Page 16 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 02:58:27 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Philippine Peso
for: Mr. HYDOE JAMES BAGON ELAN, 26, Male, Non-smoker

DECLARATIONS AND ACKNOWLEDGMENTS

DECLARATIONS

1. It is my understanding that the total premium I am going to pay when I purchase this plan shall consist of the Life BasiX premium, regular
top-up premium, and Supplement premiums shown above, if any. I was also made aware that only the Life BasiX premium and top-up
premiums will be allocated to purchase units of the investment fund/s I will choose.
2. I confirm having read and understood the information in this proposal. My Financial Advisor/Financial Executive fully explained to me the
features and charges that will be made on my plan, and that the actual variable plan benefits will reflect the actual investment experience of
the separate account into which my fund is invested. I also confirm that I will fully assume all investment gains / risks associated with the
purchase of this plan.
Acknowledgment of Variability
Variable Life Insurance Plan
I acknowledge that:

I have applied with AXA Philippines for a Variable Life Policy, and have reviewed the illustration(s) that shows how a variable life insurance
policy performs using AXA Philippines’ assumptions and based on Insurance Commission’s guidelines on interest rates.

I understand that since fund performance may vary, the values of my units are not guaranteed and will depend on the actual performance at
that given period and that the value of my Policy could be less than the capital invested. The unit values of my Variable Life Insurance are
periodically published.

I understand that the investment risks under the Policy are to be borne solely by me, as the policyholder.
Product Transparency Declaration

By signing off on the items listed below, I acknowledge that the same have been discussed with and thoroughly explained to me.
· I understand that I am buying an investment-linked insurance product.
· I understand that the principal and earnings are not guaranteed and that the value of my unit investment (NAVPU) may go up or down depending on
the performance of the separate funds.
· I understand that the funds will be invested in Equities and/or Bonds or a combination thereof, and will be subject to changes in market conditions.
· The available funds and the risks that they bear have been thoroughly discussed with me, and I have made my Fund Allocation decision based on my
own judgment of and tolerance for these risks.
· I understand that this product is appropriate for a long-term investment horizon.
· I understand that I will have zero (0) withdrawal value during the first two (2) years of the policy because the amount withdrawn will be subject to
100% surrender charge on the first two (2) years.

CONFORME: These declarations and acknowledgments are made with the knowledge of
the AXA representative whose signature appears below:

_____________________________ ____________________ _____________________________________ ________________________

Applicant/Policy Owner Date Financial Advisor/Financial Executive Date
Signature over Printed Name Signature over Printed Name

TO BE FILLED UP BY AXA PHILIPPINES

_________________________ _________________________
These declarations and acknowledgments are valid for _________________________ _________________________
the following policy/ies with policy number/s: _________________________ _________________________
Disclosure of Conflict of Interest

The Company adopts a Conflict of Interest Policy and undertakes to disclose any material information which gives rise to actual or potential conflict of interest to
our customers. Company likewise takes all reasonable steps to ensure fair dealings with our customers.

General Disclaimer

All information and opinions provided are of a general nature and for information purposes only. The information and any opinions herein are based upon
sources believed to be reliable. AXA Philippines, its officers and directors make no representations or warranty, expressed or implied, with respect to the
correctness, completeness of the information and opinions in this document. Investment or participation in the Fund(s) is subject to risk and possible loss of
principal. Please carefully read the policy and endorsements and consider the investment objectives, risks, charges and expenses before investing. You should
seek professional advice from your financial, tax, accounting or legal consultant before making an investment. Past performance is not indicative of future
performance.

THIS FINANCIAL PRODUCT OF AXA PHILIPPINES IS NOT INSURED BY THE PHILIPPINE DEPOSIT
INSURANCE CORPORATION (PDIC) AND IS NOT GUARANTEED BY METROBANK OR PS BANK.

Page 17 of 20 of Proposal N 27565-201804240642-2-02

Printed on: 5/1/2018 02:58:27 PM Created on: 4/24/2018 6:41:57 PM Expiry Date: 7/24/2018
Version Number: 3.10.13 Date for Next Insurance Age: 4/13/2019
Plan Code: BAX/ Rider Code: N/A
 Reference no.: 27565-201804240642-2-
02
INVESTMENT PORTFOLIO RISK ASSESSMENT
You prefer a growth investment portfolio
Growth Investment Portfolio : A growth investment portfolio is characterized by a willingness to accept higher than
average level of risks and price volatility in pursuit of above average returns.

- You understand that investing allows for higher returns than savings, but there is a risk that your investments
might yield negative returns and the value of your investments can even be lower than the amount you
invested
- You understand that diversifying your investments over different equity funds and bond funds reduce the
volatility of the average annual returns on your investments
- You understand that a market can be volatile and that a longer holding period in general reduces the risk of
negative average annual returns
- You prefer the possibility of a higher average annual return on your investments even if this means that there
is a probability of higher negative return in any given year.

INVESTMENT PORTFOLIO RISK ACKNOWLEDGMENT

I acknowledge that the descriptions above match the risk profile of my intended investment portfolio. I also
acknowledge that the recommended fund allocation ranges resulting from my investment portfolio risk profile is only
intended as reference to help me assess my investment portfolio’s risk appetite and investment objectives.

WAIVER FOR RISK PORTFOLIO RE-CLASSIFICATION (For Clients Investing in Products with Different Risks)

I waive the results of my investment portfolio risk profile assessment and have decided to invest instead in another
investment fund or a combination investment funds which falls outside of the recommended fund allocation ranges
indicated by my investment portfolio risk profile.

INVESTMENT POLICY STATEMENT

I acknowledge that my fund allocation represents the Investment Policy of my portfolio. I have carefully read and
understood the investment objective(s) of my selected fund(s) as well as the risk(s) that it(they) bear(s).

Conforme:

Applicant/Policy Owner Date

Signature over Printed Name
 Reference Number: 27565-201804240642-2-02

FINANCIAL UNDERSTANDING SUMMARY

Dear HYDOE JAMES

Thank you for providing us with relevant information with regards to your financial needs.

Based on your current financial situation, which includes, among others, your personal
monthly gross income of 80,000.00, and after taking into consideration your objectives, risk
profile and priorities, you have selected Life BasiX for your Income Protection need.

The details of your insurance coverage and your insurance premium are summarized in your
Life BasiX sales illustration.

MARCOS, JAYSON EBOJO

42621
27565
639999931380

This document is not intended to be a part of your sales illustration of your application form. This is a
summary of the financial needs that you have provided during assessment by your distributor.
 Reference Number: 27565-201804240642-2-02

Client's Declaration Form

I have actually read and understood the full text of the Declarations, Agreements and Acknowledgment
of the Forms before signing them:

Application Form: 27565-201804240642-2-02

Proposal/Illustration of Benefits: 27565-201804240642-2-02
Investment Portfolio Risk Assessment Form 27565-201804240642-2-02

I also understand that this Client’s Declaration Form shall form part of the insurance contract once the
Policy is issued.

HYDOE JAMES ELAN

Name and Signature Of Policy Insured

Signed On: 05-01-2018 02:57 PM

Place of Signing: MANILA