Client Information Sheet: Policy Owner Policy Insured

AXA PHILIPPINES
CLIENT INFORMATION SHEET

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

Complete Business/Company Address
E-mail Address/ Mobile No. Email: Mobile No.: Email: Mobile No.:
Telephone Number and/or Fax Number Tel No.: Fax No: Tel No.: Fax No:
Name of Spouse (if married) Age: Age:

Occupation (s) Monthly Income: Monthly Income:
Inforce Life Insurance Amount of Coverage: Amount of Coverage:
Beneficiary/ies 1 2 3 4
Full Name (Last,First,Middle Name)
Complete Residence Address
Gender Male Female Male Female Male Female Male Female

Birthday (mm/dd/yyyy) / / / / / / / /
Place of Birth
Contact Number
Occupation
Relationship to Proposed Insured
Type of Beneficiary(Primary/Secondary)
Benefit %
Annual Quarterly Credit Card
Auto-Debit Arrangement (ADA)
Mode of Payment: Method of Payment:
Monthly Post Dated Check (PDC) Cash
Proposed Insured Proposed Owner

UNDERWRITING QUESTIONAIRE (Owner to answer if payor's If "Yes", please indicate details
clause if applied for)
YES NO YES NO
1. Have you ever had an application for Life. Critical Illness, Medical or Disability insurance
that was?
a. modified, rated, or offered with reducded face amount, declined or postponed?
b. rejected for reinstatement or renewal due to health or medical reasons?
2. Have you ever made a claim for Accident , Medical Care, Critical Illness or other benefits?
3. Have you ever made a disability claim or are you presently receiving a disability benefit?
4. Are you presently incapable for work?
5. Do you participate or intend to participate in any hazardous activities related to your
occupation or any recreational e.g. scuba diving, mountaineering or climbing, skydiving
parachuting, hang-gliding, motor sports or aviation (excluding flying as a passenger on a
regular schedule airline)?
6. Have you ever taken any habit forming drugs or narcotics, or been treated or counselled
for a drug problem?
7. Do you consume alcoholic beverages? Type:
Number of drinks per day/ per week:
8. Have you ever smoked or used any of the following in the last twelve months?:
a. Cigarettes
b. e-cigarettes
c. Vape
d. Smokeless tobacco
e. Never smoked
9. Height 5'2 (ft. & in.) or 157 (cm) and weight 185 lbs. or 83. 9146 kg. State the amount gained or lost (kg):
a. Have you experienced any weight change in the last 12 months? Reason for weight change:
10. Have you ever had signs or symptoms or been told that you have or have had any medical
conditions/ illness?
a. Heart attack, chest pain, high blood pressure, stroke, high cholesterol,
high cholesterol, or any heart/
blood/ vascular diseases.
b. Cancer (including melanoma), tumor or growth of any kind.
c. Diabetes, thyroid disease, metabolic or endocrine diseases.
d. Hepatitis B or C (including Hepatitis carrier), HIV infection, liver gallbladder, ar any
gastrointestinal diseases.
e. Kidney diseases, diseases of the genitourinary system, breast diseases, or any
reproductive organ diseases.
11. In the last 5 years, have you been diagnosed, tested positive or received medical treatment
medical
treatment or been prescribed medication for any condition which has lasted longer than
7 days (other than for minor conditions such as cold or flu)?
12. Are you currently receiving any medical treatment or intend seeking or have been
advised by a physician to seek medical treatment for any health conditions or waiting the
results of any medical tests/ investigations?
13. Have your biological mother, father, brother(s) or sister(s) have been diagnosed, before
age 60, with CANCER?
a. Have your biological mother, father, brother(s) or sister(s) have been diagnosed,
before age 60, with HEART DISEASE?
b. Have your biological mother, father, brother(s) or sister(s) have been diagnosed,
before age 60, with STROKE?
c. Have your biological mother, father, brother(s) or sister(s) have been diagnosed,
before age 60, with DIABETES?
For Female Applicant only: If yes, how many months? ____________
14. Are you pregnant Expected delivery date ____________

Client Information Sheet: Policy Owner Policy Insured

Uploaded by

Copyright:

Available Formats

Client Information Sheet: Policy Owner Policy Insured

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Client Information Sheet: Policy Owner Policy Insured

Uploaded by

Copyright:

Available Formats

AXA PHILIPPINES

CLIENT INFORMATION SHEET

Complete Residence Address

Business / Company Name

Name of Spouse (if married) Age: Age:

Complete Residence Address

Gender Male Female Male Female Male Female Male Female

Proposed Insured Proposed Owner

You might also like