Health Max

Proposed Insured: Age 28, Male, Non-smoker Policyowner or Payor: Age 28, Male

Dear MARK ANTHONY, Thank you for your interest in AXA’s insurance products. Health MaX is a lifetime health plan which provides coverage for major and minor critical conditions to ensure that you will have the necessary funding for treatment and recovery. It also gives you lifetime insurance coverage so you can be sure that your loved ones will be financially protected when the unexpected happens. Enjoy the following benefits from

: of

1,000,000 if you are diagnosed with any of the 56 specified major

of

200,000 is advanced if you are diagnosed with any of the 18 specified

·

critical conditions. ·

minor critical conditions. During the life of your policy, you can claim a maximum of two of two (2) minor critical conditions. in the form of guaranteed cash endowments, which you have the option to withdraw for health expenses

·

such as outpatient treatments and medicines equivalent to

200,000 by age 70 up to

500,000 if left to accumulate, by

age 85. of

·

1,000,000 from day one of policy issuance.

that can be used should there be unexpected need for funds.

·

* The Major Critical Conditions and Life Insurance Benefits are equal to 100% of the sum insured if there are no withdrawals made for the Advanced Health Fund and there are no claims for Minor Critical Conditions Conditions benefit. Any claims, withdrawals, withdrawals, or policy loans will be deducted to the benefits payable accordingly. accordingly. ** The payable Minor Critical Conditions Benefit should come from different Minor Critical Conditions except for (i) Angioplasty and Other Invasive Treatments for Coronary Artery, and (ii) Carsinoma-in-situ. Carsinoma-in-situ.

The Supplements The Supplements provide you with additional benefits, giving your policy an edge over other instruments: o

CARE guarantees daily hospitalization benefit of PHP 5,000/day (PHP 10,000/day if under intensive care).

BENEFITS For You (Living benefits)

For Your Loved Ones (Death Benefits)

(Major Critical Conditions Benefits)

Total Living Benefit (Guaranteed Cash Value + Accumulated Accumulated Advanced Health Fund with Interest)

Guaranteed Major Critical Conditions Benefit + Accumulated Accumulated Advanced Health Fund with Interest

Guaranteed Death Benefit + Accumulated Accumulated Advanced Health Fund with Interest

Based on 3% Accumulation

Based on 3%

Based on 3%

Interest Rate……………PHP 782,855

Accumulation Rate…..……PHP 1,031,855

Accumulation Rate…..……PHP 1,031,855

Or

Or

Or

Based on 3.5% Accumulation

Based on 3.5%

Based on 3.5%

Interest Rate.…….......PHP 788,537

Accumulation Rate.….......PHP 1,037,537

Accumulation Rate.….......PHP 1,037,537

The above is only a summary of the benefits illustration. All the amounts shown are based on the assumption that Advanced Health Fund payouts are left with the Corporation to earn interest. For more information on the above benefit details, please refer to the succeeding pages.

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Version Number: 2016.18.3 - 01 Plan Code: HMAX20 HMAX20 / Rider Code: MEB7

Expiry ExpiryDat Date:9 e:9/24 /24/20 /2017 17 DateforNextInsuranceAge:3/28/2018

for: Ms. MARK ANTHONY ARELLANO NIDOY, 28, Male, Non-smoker

·

Major Critical Conditions Benefit if the Insured is diagnosed

1,000,000

with one of the 56 covered Major Critical Conditions* ·

Minor Critical Conditions Benefit if the Insured is diagnosed

200,000 up to a maximum of two (2) claims

with one of the covered Minor Critical Conditions** ·

Death Benefit in the unfortunate event that the Insured

1,000,000

passes away, the beneficiary will receive this amount* ·

Accumulated Advanced Health Fund ***

200,000 350,000 450,000 500,000

at at at at

Age 70 Age 75 Age 80 Age 85

*The benefit amount for Major Critical Conditions and Death Benefits assumes that there are no claims made for Minor Critical Conditions Benefit and there no withdrawals from the Advanced Health Fund. Any claims, withdrawals, or policy loans will be deducted to the benefit payable accordingly. **The amount of benefit paid or payable will be deducted from the Major Critical Conditions Benefit and Death Benefit payable under the Basic Plan. Please refer to the conditions stated on the subsequent pages for the covered ill nesses. The payable Minor Critical Conditions Benefit should come from different Minor Critical Conditions except for (i) Angioplasty and Other Invasive Treatments for Coronary Artery, and (ii) Carcinoma-in-situ. ***The benefit amount for Advanced Health Fund assumes that there are no withdrawals made until age 85. The Advanced Health Fund may increase if left with the Company to accumulate with interest.

The succeeding pages of this proposal provide more details on the benefits and features of Health MaX . Again, thank you for your interest in our products. If you have questions, please call me at the number specified below or call the AXA Customer Care Hotline at Tel. No. 5815-292 or 3231-292

VALDEZ, AURORA PULIDO 71615 024918 639985481017


Createdon:6/24/201710:31:33PM

Version Number: 2016.18.3 - 01 Plan Code: HMAX20 / Rider Code: MEB7

ExpiryDate:9/24/2017 DateforNextInsuranceAge:3/28/2018


PREMIUMS Plan/Supplements

Cover up to Age*

HEALTH MAX 20-PAY

100

CARE PREMIER (20 YEARS)

48

Sum Insured / Coverage (PHP)

Annual Premium (PHP)

1,000,000

24,150.00

-

9,665.42

Total Initial Annual Premium

33,815.42

Semi-Annual Premium

17,584.02

Quarterly Premium

9,130.16

Monthly Premium

3,212.46

*Cover up to Age refers to Termination Age Notes: The premium rates for Health MaX are not guaranteed and the Company reserves the right to review and adjust the premium rates from time to time. We will communicate any change in premium rates by mail or in any other applicable form. 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.


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for: Ms. MARK ANTHONY ARELLANO NIDOY, 28, Male, Non-smoker ILLUSTRATION OF LIVING BENEFITS 3% Accumulation Rate

Guaranteed Cash Value

Accumulated Advanced Health Fund

Accumulated Advanced Health Fund with Interest

3.5% Accumulation Rate

End of Year

Attained Age

Total Living Benefit

1 2 3 4 5 6 7 8 9 10 15 20 25

29 30 31 32 33 34 35 36 37 38 43 48 53

0 0 1,000 15,000 33,000 51,000 70,000 90,000 112,000 136,000 261,000 393,000 452,000

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 1,000 15,000 33,000 51,000 70,000 90,000 112,000 136,000 261,000 393,000 452,000

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 1,000 15,000 33,000 51,000 70,000 90,000 112,000 136,000 261,000 393,000 452,000

42 47 52 57 62 67 72

70 75 80 85 90 95 100

465,000 401,000 360,000 334,000 365,000 368,000 500,000

200,000 350,000 450,000 500,000 500,000 500,000 500,000

200,000 381,855 542,674 679,108 787,273 912,665 1,058,029

665,000 782,855 902,674 1,013,108 1,152,273 1,280,665 1,558,029

200,000 387,537 560,273 715,428 849,704 1,009,182 1,198,592

665,000 788,537 920,273 1,049,428 1,214,704 1,377,182 1,698,592

1. 2.


Total Living Benefit

The presents the amounts payable to the Owner once he/she decides to surrender/terminate the plan. The (3% & 3.5%) are assumed annual rates and are for illustration purposes only, and do not represent maximum or minimum cash returns. 3. The plan provides , which can be paid to the Owner upon termination of the policy prior to death. Any Minor Critical Conditions benefit claims paid are deductible from the Guaranteed Cash Value. At any time the total Minor Critical Conditions benefit paid is higher than the Guaranteed Cash Value, the surrender amount is reduced to zero. 4. The refers to the accumulated cash endowment benefits available on the 70 th, 75th, 80th, and 85 th birthdays of the Insured. 5. The is the sum of the Guaranteed Cash Value, and the Accumulated Advanced Health Fund with Interest (if any). The Advanced Health Fund benefits are to be available 1 day after the end of the policy year. Interest rates on Accumulated Advanced Health Fund are not guaranteed, as these are dependent on the investment performance of the 6. Corporation. 7. The Illustration assumes that your Advanced Health Fund payouts are left with the Corporation to earn interest. If you decide to withdraw your Advanced Health Fund, the total living benefits will be reduced accordingly. The plan offers Extended Term Insurance and Premium Loan as premium default options. 8. 9. All amounts are in the currency indicated in the Summary of Benefits page. 10. This proposal is only an illustration of the key features, benefits and assumptions of the recommended insurance plan and does not form part of the contract. For the complete terms, conditions and limitations of the plan please refer to your policy.


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3% Accumulation Rate

End of Year

Attained Age

1 2 3 4 5 6 7 8 9 10 15 20 25

29 30 31 32 33 34 35 36 37 38 43 48 53

42 47 52 57 62 67 72

70 75 80 85 90 95 100

Guaranteed Death Benefit / Major Critical Conditions Benefit

Accumulated Advanced Health Fund


Total Death Benefit /Major Critical Conditions Benefit

3.5% Accumulation Rate


Total Death Benefit /Major Critical Conditions Benefit

1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000

0 0 0 0 0 0 0 0 0 0 0 0 0

1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000

800,000 650,000 550,000 500,000 500,000 500,000 500,000

200,000 350,000 450,000 500,000 500,000 500,000 500,000

200,000 381,855 542,674 679,108 787,273 912,665 1,058,029

1,000,000 1,031,855 1,092,674 1,179,108 1,287,273 1,412,665 1,558,029

200,000 387,537 560,273 715,428 849,704 1,009,182 1,198,592

1,000,000 1,037,537 1,110,273 1,215,428 1,349,704 1,509,182 1,698,592

The

is the sum of the , and the (if any) payable upon the demise of the Insured or the Insured’s diagnosis of any of the 56 Major Critical Conditions. The Advanced Health Fund payable on the 70 th, 75 th, 80 th and 85th birthdays will be credited 1 day after the end of the policy year following the 70 th, 75th, 80th and 85th birthdays. The figures presented are based on the key features, benefits and assumptions listed on the Benefits page.


Createdon:6/24/201710:31:33PM



portion found in the Illustration of Living


Cancer 1.

Critical Conditions related to the digestive system

Cancer

39. 40. 41. 42.

Critical Conditions related to organ failure 2. 3. 4. 5. 6. 7. 8. 9.

Critical Conditions related to immunology and rheumatology

Chronic Adrenal Insufficiency (Addison's Disease) Chronic and Irreversible Kidney Failure Chronic Liver Disease Coma E nd S ta ge L un g Di sea se Loss of Independent Existence# Major Organ Transplantation Medullary Cystic Disease

43. 44. 45.

Critical Conditions related to heart and blood vessels 10. 11. 12. 13. 14. 15. 16. 17. 18.

Cardiomyopathy Coronary Artery Disease Requiring Surgery Dissecting Aortic Aneurysm Eisenmenger’s Syndrome Heart Attack Heart Valve Surgery Primary Pulmonary Arterial Hypertension Severe Infective Endocarditis Surgery to Aorta Amyotrophic Lateral Sclerosis Apallic Syndrome Bacterial Meningitis Benign Brain Tumor Blindness Brain Damage^ Encephalitis Motor Neuron Disease Multiple Sclerosis Muscular Dystrophy P ar al ys is Poliomyelitis Progressive Bulbar Palsy Progressive Supranuclear Palsy^ Spinal Muscular Atrophy Stroke Tuberculosis Meningitis AIDS / HIV due to Blood Transfusion Aplastic Anemia Occupationally Acquired AIDS / HIV

Alzheimer’s Disease Parkinson’s Disease Severe Creutzfeld-Jacob Disease (CJD)

Critical Conditions related to the musculoskeletal system 49. 5 0. 51. 52.

Critical Conditions related to blood 36. 37. 38.

Severe Rheumatoid Arthritis Systemic Lupus Erythematosus (S.L.E.) with Lupus Nephritis Systemic Scleroderma

Critical Conditions related to neurological degeneration 46. 47. 48.

Critical Conditions related to the nervous system 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 2 9. 30. 31. 32. 33. 34. 35.

Chronic Relapsing Pancreatitis Fulminant Hepatitis Severe Crohn’s Disease Severe Ulcerative Colitis

Amputation of Both Feet due to Complication from Diabetes M ajo r Bu rns Necrotizing Fasciitis Severance of Limbs

Other Critical Conditions 53. 54. 55. 56.

Deafness (loss of hearing) Elephantiasis Loss of Speech Terminal Illness

#To be eligible to receive a benefit under this Major Critical Condition, the Insured must be between age 15 and age 75 at the time of first diagnosis. ^To be eligible to receive a benefit under this Major Critical Condition, the Insured must be above age 5 at the time of first diagnosis.

Children Minor Critical Conditions~

1. 2. 3. 4. 5. 6. 7. 8.

Dengue Hemorrhagic Fever (Grades III and IV) Hemophilia A and Hemophilia B Insulin Dependent Diabetes Mellitus Kawasaki D isease Osteogenesis Imperfecta Rheumatic Fever with Valvular Impairment Still’s Disease W ils on’ s Di se as e

Carcinoma-in-situ / Early Stage Cancer

9. 10.

Carcinoma-in-situ at Breast, Cervix Uteri, Uterus, Ovary, Fallopian Tube, Vagina or Testicles Early Stage Cancer of Prostate

11.

Angioplasty and Other Invasive Treatments for Coronary Artery Disease

12. 13. 14. 15. 16. 17. 18.

Aortic Aneurysm Chronic Auto-immune Hepatitis Facial Reconstructive Surgery for Injury due to Accident Hepatitis with Cirrhosis Insertion of Pacemaker or Defibrillator Skin Transplantation due to Accidental Burning Systemic Lupus Erythematosus (S.L.E.)

Angioplasty Other Minor Critical Conditions

~Only an Insured aged under 22 on the 1st diagnosis of these minor Critical Conditions is eligible to claim for the relevant benefit. : The critical condition must occur for the corresponding Major Illness or Minor Illness Benefit to be payable. Benefits relating to Major and Minor Critical Conditions are payable according to the definitions of Major and Minor Critical Conditions Benefits as set out in the policy contract.


Createdon:6/24/201710:31:33PM




QUICK GUIDE TO COMMON CRITICAL CONDITIONS COVERED UNDER YOUR HEALTH PLAN Health Max covers a total of 56 major and 18 minor critical conditions. Here is a quick reference for the 15 most common major critical conditions and 5 minor critical conditions.

1. Cancer

Cancer beginning stage 1* to stage 4, which meets the following criteria: • A malignant tumor • Confirmed by biopsy report • Certified by an appropriate specialist Types of Cancer include: Leukemia, Malignant Lymphoma, Hodgkin’s Disease, Malignant bone marrow disorders, Metastatic cancers

• • •

• *except for certain stage 1 cancer classifications in specified organs 2. Stroke

Evidence of irreversible death of brain cells due to a blocked artery or ruptured blood vessel.

• • •

•

• • •

Tumors defined as benign, or pre-malignant Non-invasive cancers in situ (pre-cancer or Stage 0 cancer) Certain Stage 1 cancer classifications in the contract for the following organs: ovary, prostate, urinary bladder, and thyroid Any skin cancer other than malignant melanoma Chronic Lymphocytic Leukemia less than Rai Stage 3. Transient Ischaemic Attacks (TIA) or temporary stroke-like signs and symptoms Brain damage due to an accident or injury, infection, vasculitis (inflammation of blood vessels), inflammatory disease or migraine Disorders of the blood vessels affecting the eye including infarction of the optic nerve or retina Ischemic disorders of the vestibular system Silent stroke with no symptoms

3. Heart Attack

Occurrence of death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area.

4. Coronary Artery Bypass Graft Surgery (CABG)

An open heart surgery should have already been done to correct the narrowing or blockage of one or more coronary arteries with bypass grafts.

•

All other procedures which do not require open chest surgery and actual placement of bypass graft

5. Heart Valve Surgery

An open heart valve surgery should have already been done to replace or repair one (1) or more heart valves, as a consequence of defects.

•

All repairs conducted through intra-arterial catheter procedures

6. Major Organ Transplantation

Recommendation from a specialist to undergo transplant for any of the following organs: • heart, lung, liver, kidney, pancreas, or human bone marrow

•

Other transplants for organs not mentioned in the list

7. Chronic and Irreversible Kidney Failure

The following symptoms must be present: Both kidneys are characterized with irreversible • failure to function • Has already started regular renal dialysis • Is either awaiting or has already undergone kidney transplant

•

At least one kidney is still functioning and regular dialysis is not required.

8. Alzheimer’s Disease

Evident deterioration or loss of cognitive and/or intellectual capacity, due to irreversible failure of brain function.

•

Dementia relating to alcohol, drug abuse or AIDS

Any chest pain (i.e. angina) without evidence of death or injury of the heart muscle

: The critical condition must occur for the corresponding Major Illness or Minor Illness Benefit to be payable. Benefits relating to Major and Minor Critical Conditions are payable according to the definitions of Major and Minor Critical Conditions Benefits as set out in the policy contract.


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9. Parkinson’s Disease

Definitive signs of progressive and permanent neurological impairment, evidenced by permanent inability to perform at least three (3) out of six (6) Activities of Daily Living (ADLs)1 , in spite of being on optimal medication.

•

Drug induced, accidental, or toxic causes of Parkinson’s Disease

10. Bacterial Meningitis

Evidence of inflammation of the brain membranes or spinal cord, resulting in significant and permanent neurological deficit.

•

Viral Meningitis

11. Benign Brain Tumor

Presence of a life threatening, non-cancerous tumor in the brain. If it cannot be removed through surgery, the tumor should cause significant and permanent neurological deficit persisting for at least 6 consecutive months.

•

Cysts, granulomas (inflammations), malformations in, or of, the arteries or veins of the brain, hematomas (collection of blood outside the blood vessels) and tumors in the pituitary gland or spinal cord

12. Paralysis

Inability of two (2) or more limbs to function totally and permanently due to injury or disease of the spinal cord or brain.

•

Paralysis in 1 limb

•

Independent capability to perform 4 or more ADLs

•

Only one joint area is affected and the Insured can still perform 3 or more ADLs.

•

Loss of either one (1) hand or one (1) foot only.

Those classified as Diplegia (paralysis affecting like parts on both sides of the body, such as both arms or both legs), Hemiplegia (paralysis of one side of the body), and Quadriplegia (paralysis of all four limbs) are included. Permanent inability to perform at least three (3) Activities of Daily Living (ADLs) 1 , as certified by a medical specialist and/or AXA’s medical director.

13. Loss of Independent Existence

*Only Insured aged between 15 and 75 on first diagnosis is eligible to receive a benefit under this illness Evidence of extensive joint deformity of two (2) or more of the following joint areas: hands, wrists, elbows, knees, hips, ankle, cervical spine or feet; and inability to perform at least 2 Activities of Daily Living (ADLs)1 .

14. Severe Rheumatoid Arthritis

The condition must be present for at least six (6) months. 15. Severance of Limbs

Total and irrecoverable loss of two (2) or more limbs due to illness or accident only. This includes the loss of use of both hands or both feet or the use of one (1) hand and one (1) foot.

1 Activities

of Daily Living are as follows: (1) - wash in the bath or shower (including getting into and out of the bath or shower) or wash satisfactorily by other means; (2) - put on, take off, secure, and unfasten all garments and, as appropriate, any braces, artificial limbs, or other surgical appliances; (3) - move from a bed to an upright chair or wheelchair or vice versa; (4) - move indoors from room to room on level surfaces; (5) - use lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory level of personal hygiene; and (6) - feed oneself once food has been prepared and made available. : The critical condition must occur for the corresponding Major Illness or Minor Illness Benefit to be payable. Benefits relating to Major and Minor Critical Conditions are payable according to the definitions of Major and Minor Critical Conditions Benefits as set out in the policy contract.

NOTE: Benefits relating to major and minor Critical Conditions are payable according to the definitions set out in the policy contract .


Createdon:6/24/201710:31:33PM




1. Carcinoma-in-situ (CIS) commonly known as Pre-Cancer or Stage 0 cancer

Cells on biopsy have not yet spread and invaded surrounding tissues or are contained to the place of origin.

•

Carcinoma-in-situ located in organs not specified in the definition

•

Angioplasty, atherectomy, or laser treatment has not yet been performed The procedure was done only for the branches of the major coronary arteries

Only CIS reported in any of the following organs may be covered: Cervix Uteri, Uterus, Breast, Vagina, Fallopian Tube, Ovary, Testicles Maximum of 2 claims, with the 2nd CIS claim for any of the other remaining organs listed and not from the same organ as that of the 1st CIS claim. 2. Angioplasty and other Invasive Treatments for Coronary Artery Disease

Have already undergone Angioplasty (procedure to widen blocked or narrowed coronary arteries), atherectomy (procedure to remove plaque from the inside of a blood vessel) or laser treatment to correct narrowings.

•

Covered procedure should involve any of the following coronary vessels: Left main stem artery, Left anterior descending artery, Circumflex artery, Right coronary artery except their branches Maximum of 2 claims, with the 2nd procedure done in a narrowed vessel of a major coronary artery. 3. Early Stage Cancer of Prostate

A prostate malignant tumor histologically described as TNM classification T1a, T1b, T1c or which is of another equivalent classification. Diagnosis must be supported by a biopsy report.

•

The condition does not satisfy all of the specified criteria.

4. Hepatitis with Liver Cirrhosis

Inflammation of the liver by the Hepatitis virus leading to cirrhosis (healthy liver tissue is replaced with scar tissue, eventually preventing the liver from functioning properly).

•

Liver diseases due or related to alcohol abuse

•

Dengue Hemorrhagic Fever I and II

The liver biopsy must show score 4 in Metavir grading system or score 13-18 in Knodell score system or any other imaging test establishing existence of cirrhosis. Dengue Grades III and IV

5. Dengue Hemorrhagic Fever

*Only Insured aged 21 and below on first diagnosis is eligible to receive a benefit under this illness. : The critical condition must occur for the corresponding Major Illness or Minor Illness Benefit to be payable. Benefits relating to Major and Minor Critical Conditions are payable according to the definitions of Major and Minor Critical Conditions Benefits as set out in the policy contract.


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Attached Supplements Summary of the Riders Attached to this Proposal CARE pays a specific amount to defray the cost of hospital confinement/admission due to sickness or injury, based on the following schedule: CONFINEMENT/ADMISSION BENEFITS

ECONOMY

SUPERIOR

PREMIER

General Admission (up to 1,000 days)

P800/day

P2,000/day

P5,000/day

Intensive Care (up to 120 days)

P1,600/day

P4,000/day

P10,000/day

CARE Premiums are payable up to age 48. NOTES: 1.

The rates shown, if any, are those currently in effect. The rates may change subject to the approval of the Insurance Commission.

2.

For a detailed description of the Supplements, including exclusions and other provisions, please refer to the policy contract.

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I confirm having read and understood the information contained in the Illustration of Living Benefits Page and the Illustration of Death Benefits / Major Critical Conditions Benefits Page.

I acknowledge that:

I have applied with AXA Philippines a Whole Life policy, and have reviewed the illustration(s) that shows how a life insurance policy performs using the company’s assumptions based on Insurance Commission’s guidelines on interest rates. I understand that only those values described as guaranteed, if any, are guaranteed. All other policy values can change and may probably be different from those illustrated to me. Actual values may be higher or lower depending on the dividend rates actually earned. I understand that

change from year to year and since these are affected

by the company’s mortality experience, investment returns, expenses, and taxes, and that AXA Philippines will advise me of the actual amount of the interest rate, if any. I understand that the illustration(s) given to me will not become part of any issued policy, as these are provided only to show how policy benefits would change over time under a specific set of assumptions.

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

CONFORME:

____________________________ Applicant/Policy Owner Signature over Printed Name

_____________________ Date

____________________________________ Financial Advisor/Financial Executive Signature over Printed Name

_____________________ Date

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.

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Health Max

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