Escolar Documentos
Profissional Documentos
Cultura Documentos
511 - 1806153
Accomplish the details and put “N/A” if not applicable. Print legibly using BLACK 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.
FOR OFFICE USE ONLY
Important Notes:
Date Received:
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 Time Received:
insurer. All answers to the questions stipulated in this questionnaire are the Receiving
basis of and are an inseparable part of the insurance policy. In case of doubt Dept./Office:
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).
LAST NAME
REBUYON
FIRST NAME Notes
BUSINESS ADDRESS
Unless you are a bank
BUSINESS NAME/NAME OF EMPLOYER (Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE employee, Bank address
and contact information
DEPARTMENT OF LABOR AND EMPL 102 ACEPAL BUILDING MABINI EXT BARANGAY ZONE IV 9506 should not be used
KORONADAL CITY SOUTH COTABATO
CONTACT INFORMATION
HOME PHONE NUMBER MOBILE NUMBER (Mandatory)
0 639989559152
BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory) Answer this question only
if Proposed Insured is the
0 KIDERNEST23@GMAIL.COM same as the Proposed
Owner
SOURCE OF FUNDS/MONTHLY INCOME
Salaries/Php 20000.00 Income from business/Php Savings/Php 10000.00
MAMRXXEXREG-1118 1 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
LAST NAME
Notes
BUSINESS ADDRESS
BUSINESS NAME/NAME OF EMPLOYER (Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE
CONTACT INFORMATION
HOME PHONE NUMBER MOBILE NUMBER (Mandatory)
MAMRXXEXREG-1118 2 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
*TYPE OF IRREVOCABLE
NAME PRESENT PLACE OF DATE OF NATURE OF RELATIONSHIP BENEFIT BENEFICIARY (Please shade if Surviving Beneficiaries in
(Last, First, Middle Name) ADDRESS BIRTH BIRTH WORK TO PROPOSED % (optional) Irrevocable the same classification
Beneficiary)
INSURED Primary Secondary will equally share in the
benefits.
BLK. 1 LOT 15 DONA LOURDES
REBUYON, MILROSE SUB BARANGAY ZONE II KORONADAL Office
1968/02/21 Parent 50 Designation of a minor as
MADAYAG KORONADAL CITY SOUTH CITY Employee/Staff
COTABATO Irrevocable beneficiary
BLK. 1 LOT 15 DONA LOURDES is discouraged.
REBUYON, NIKKO JAN PAOLO SUB BARANGAY ZONE II KORONADAL
2003/01/26 Student Sibling 50
MADAYAG KORONADAL CITY SOUTH CITY Secondary Beneficiaries
COTABATO are entitled to the benefits
if no Primary Beneficiary
survives
5. BASIC PLAN DETAILS
When policy owner (PO)
designates a revocable
BASIC SUM INSURED SINGLE PREMIUM beneficiary, the PO may change
PREMIUM TYPE CURRENCY the policy details, including its
Regular-Pay Single-Pay Peso Dollar beneficiaries, any time.
400,000.00 However, when PO designates
irrevocable beneficiary, PO
PLAN NAME PAYMENT TERM, If applicable YEARS TO MATURE, If applicable may not change the details of
the policy, without prior
Life BasiX Level Death Benefit consent of said irrevocable
beneficiary.
PURPOSE OF THE INSURANCE APPLIED FOR:
Income protection Retirement planning Business continuation/ Keyman insurance Fringe benefit
Single Premium refers
Children’s protection Education funding Outstanding mortgage loan Estate planning to a single one-off
payment that covers
(Beneficiaries are preferably “irrevocable”) the entire cost of
Savings Others
the Policy.
6. SUPPLEMENT DETAILS
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Application for Life Insurance Application Number R 39803-201907120719-2-02
2. Opportunity Fund 10 5.
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Application for Life Insurance Application Number R 39803-201907120719-2-02
11. DECLARATION OF PROPOSED INSURED and OWNER (If Payor’s Clause is applied for)
1. Have you ever had an application for Life, Critical Illness, Medical or
Disability insurance that was:
a. modified, rated or offered with reduced face amount, declined or Yes No Yes No
postponed?
b. rejected for reinstatement or renewal due to health/medical reasons? Yes No Yes No
2. Have you ever made a claim for Accident, Medical care, Critical Illness or Yes No Yes No
other benefits?
3. Have you ever made a disability claim or are you presently receiving a Yes No Yes No
disability benefit?
4. Are you presently incapable for work? Yes No Yes No
Medical Questions
2. Have you ever had signs or symptoms or been told that you have or have
had any of the following medical conditions:
a. Heart attack, chest pain, high blood pressure, stroke, high cholesterol, Yes No Yes No
or any heart/blood/vascular diseases.
e. Kidney diseases, diseases of the genitourinary system, breast diseases, Yes No Yes No
or any reproductive organ diseases.
3. In the last 5 years, have you been diagnosed, tested positive or received
medical treatment or been prescribed medication for any condition Yes No Yes No
which has lasted longer than 7 days (other than for minor conditions
such as cold or flu)?
Disclosure: In accordance with the Insurance Commission’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.
MAMRXXEXREG-1118 5 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
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
MAMRXXEXREG-1118 6 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
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.
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.
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.
MAMRXXEXREG-1118 7 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
**(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.
Code: Code:
212020 4 39803
Signature: Signature:
I ensure that I, as the distributor, have guided the client in completing all relevant and necessary information to assist the Company in assessing the application. I further
declare that:
1. The information provided by the client in the application form are accurate and complete;
2. I/We also certify that I/we saw the Proposed Insured (and Owner, if applicable) and have verified his/her identity at the time of signing this application;
3. 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; and
4. Any additional information that shall be required by the Company in order to determine any particular application shall be provided on a timely basis.
Signature: Signature:
MAMRXXEXREG-1118 8 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
Please refer to the back page for the Declaration and Reminders of this application form
Cardholder's Name:
Contact Number(s) of
Cardholder:
Parent Spouse Sibling Child (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 Enrollment Form. 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.
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Application for Life Insurance Application Number R 39803-201907120719-2-02
MAMRXXEXREG-1118 10 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
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 publicassistance@insurance.gov.ph.
The official website of the Insurance Commission is www.insurance.gov.ph.
MAMRXXEXREG-1118 11 of 23
Second Level Answers Reference Number: 39803-201907120719-2-02
Lifestyle 1. Have you ever had an application for Life, Critical Illness, Medical or
Yes
Disability insurance?
Have your biological mother, father, brother(s) or sister(s) been diagnosed,
Yes
before age 60, with HEART DISEASE?
Please indicate number of affected relatives diagnosed with Heart Disease before
1 first degree relative
age 60:
Have your biological mother, father, brother(s) or sister(s) been diagnosed,
Yes
before age 60, with STROKE?
Please indicate number of affected relatives diagnosed with Stroke before age 60: 1 first degree relative
Have your biological mother, father, brother(s) or sister(s) been diagnosed,
Yes
before age 60, with DIABETES?
Please indicate number of affected relatives diagnosed with Diabetes before age
1 first degree relative
60:
Have your biological mother, father, brother(s) or sister(s) been diagnosed,
Yes
before age 60 with OTHER INHERITED CONDITIONS?
Please provide affected relative/s and medical condition/s Asthma
Proposed Insured:
Mr. KID ERNEST JONES MADAYAG REBUYON
Age 23, Male, Non-smoker
Policyowner or Payor:
Mr. KID ERNEST JONES MADAYAG REBUYON
Age 23, Male
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 14,764.00 annually, you get to enjoy the following benefits:
BENEFITS
For You For Your Loved Ones
(Living Benefits) (Death Benefits)
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 4.00%, 8.00%, and 10.00%. 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.
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.
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 73,8201.
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 100 400,000 14,764.00
Total² 14,764.00
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.
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 14,764 7,511 400,000 7,836 400,000 7,998 400,000
2 29,528 15,330 400,000 16,306 400,000 16,805 400,000
3 44,292 23,474 400,000 25,469 400,000 26,507 400,000
4 59,056 31,952 400,000 35,376 400,000 37,192 400,000
5 73,820 40,783 400,000 46,093 400,000 48,966 400,000
10 147,640 118,646 400,000 145,715 400,000 161,711 400,000
15 221,460 220,382 400,000 301,180 400,000 353,691 400,000
20 295,280 339,117 400,000 523,945 523,945 656,279 656,279
25 369,100 501,668 501,668 877,792 877,792 1,176,830 1,176,830
30 442,920 682,922 682,922 1,371,513 1,371,513 1,982,007 1,982,007
35 516,740 903,444 903,444 2,096,950 2,096,950 3,278,752 3,278,752
40 590,560 1,171,743 1,171,743 3,162,856 3,162,856 5,367,174 5,367,174
45 664,380 1,498,170 1,498,170 4,729,021 4,729,021 8,730,598 8,730,598
50 738,200 1,895,319 1,895,319 7,030,230 7,030,230 14,147,426 14,147,426
55 812,020 2,378,511 2,378,511 10,411,463 10,411,463 22,871,282 22,871,282
60 885,840 2,966,387 2,966,387 15,379,602 15,379,602 36,921,139 36,921,139
This illustration shall form part of the insurance contract once the Policy is issued.
The following table is an example of the impact of a premium holiday at year [PremiumHolidayYear] 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.
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
[PremiumHolidayYear] 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.
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.
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.
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:
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.
- 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.
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.
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:
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 20,000.00, and after taking into consideration your objectives, risk
profile and priorities, you have selected Life BasiX for your Wealth Management need.
The details of your insurance coverage and your insurance premium are summarized in your
Life BasiX sales illustration.
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: 39803-201907120719-2-02
I also understand that this Client’s Declaration Form shall form part of the insurance contract once the
Policy is issued.
Signed On:
Place of Signing: