Supplementary proposal

This form is to be used for the following purposes only:

1. Completion of omissions or unanswered questions in the proposal form (indicate question number)
2. Additional declaration or clarification pertaining to health, financial, occupation, avocation, residency information
3. Change in proposer (a new proposal form, Policy Illustration and FNA has to be submitted with this form)
4. Change in plan (a new Policy Illustration and FNA has to be submitted with this form)
Note: For changeof plan from Non-ILP toILP plan, CKA and Risk Profiling must beconducted.
5. Change in age or fund details for investment-linked plan (a new Policy Illustration has to be submitted)
Note: Proposer has to confirm that the new fund selection is “in line” or “not in line” with the risk profile.
6. Request for backdating (age should match the Policy Illustration)
7. Changes in mode and method of payment (a new Policy Illustration has to be submitted for Investment-linked plan)



ѷ

0-.0)/
/*
 /$*)
сфҗфҘ
*!
/#

).0-)
/
*!
$)"+*-
җ
русҘѶ
4*0
-
/*
$.'*.
$)
/#$.
+-*+*.'
!*-(Ѷ
!0''4

)
!$/#!0''4Ѷ
''
/#
!/.
2#$#
4*0
&)*2
*-
*0"#/
/*
&)*2Ѷ
*-
/#
+*'$4
$..0 
 '*2
(4

1*$ѵ

Application / Policy No : ___________________________________

Name of life assured : ___________________________________

Name of proposer / Policyholder (if other than life assured) : ___________________________________

I or We* declare that the foregoing statements are to the best of my or our* knowledge and belief,
true and complete and that they shall form part of my or our* application dated
__________________ .

Witnessed by Financial Consultant Signature of proposer

Note:
(if other than life assured)
* Please delete where
Date: Date: applicable
Ver.Jul 2019

AXA Insurance Pte Ltd (Company Reg. No. 199903512M)

8 Shenton Way #24-01 AXA Tower Singapore 068811
AXA Customer Centre #01-21/22 Tel: 1800 880 4888
Website: www.axa.com.sg