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SUPPLEMENTARY PROPOSAL FORM (NEW BUSINESS)

Proposal Information

Proposal Number Name of Financial Consultant Agency Number

-
WARNING: PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT (CAP 142), YOU ARE TO DISCLOSE IN THIS PROPOSAL FORM FULLY AND
FAITHFULLY, ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE YOU MAY RECEIVE NOTHING FROM THE POLICY.
Name of Life/Live(s) to be Assured* NRIC/Passport/BC No. Name of Proposer(s)* NRIC/Passport/BC No.
(if other than Life/Live(s) to be Assured)

* If there is more than one Life to be Assured/Proposer, please complete details, if applicable.

Section A: Details of Changes

Please provide details of changes below, where applicable.

1) Plan type, Sum Assured, Premium amount, revised premium, etc
2) Question number of proposal form, questionnaire, etc

Declaration
I/We declare that the information given in this supplementary proposal form is true and that such information and any other i nformation supplied to Prudential or to the Medical Examiner of
Prudential shall be the basis of the policy of assurance or revised policy of assurance, as applicable. I/We declare that no material facts, that are facts likely to influence the assessment and
acceptance of the proposal or revision of the policy of assurance, have been withheld and to the best of my/our knowledge and belief, the information given herein is true and complete and
in the case of a life of another assurance shall be the basis of the revised contract.
I/We agree to inform Prudential if there is any change in the state of health, occupation or activity of the Life to be Assured between the date of this supplementary proposal form or medical
examination and the issue of the policy. On receiving this information Prudential is entitled to accept or reject the proposal.
I/We agree and authorise
a) Any medical source, insurance office or organization to release to Prudential; and
b) Prudential to release to any medical source or insurance office
any relevant information concerning the Life to be Assured at any time, irrespective of whether the proposal is accepted by Prudential. A photographic copy of this authorisation shall be as
valid as the original.
I/We declare that I/we have received a copy of “Your Guide to Life Insurance”; or “Your Guide to Health Insurance” or both, “PruPlanner/Financial Need Analysis”, “Product Summary”, and
“Policy Illustration”; the contents of which had been explained to me/us to my/our satisfaction.
I/We further declare that I/we are not an undischarged bankrupt and that I/we have committed no act of bankruptcy within the last twelve months and that no receiving order or adjudication
in bankruptcy has been made against me/us during that period.
If a material fact is not disclosed in the proposal form or in this supplementary proposal form, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are
advised to disclose it. This includes any information that you may have provided to the adviser but was not included in the proposal form or in this supplementary proposal form. Please
check to ensure you are fully satisfied with the information declared in the proposal form and in this supplementary proposal form.

Signature of Life/Live(s) to be Assured** Signature of Proposer(s)**

(If other than Life/Live(s) to be Assured)

Dated in Singapore on Dated in Singapore on

N07/18

(DD/MM/YY): (DD/MM/YY):

**If there is more than one life to be Assured/Proposer, all lives to be assured/proposers are to sign within the box.

Prudential Assurance Company Singapore (Pte) Limited (Reg. No.: 199002477Z) L1SUPPF
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