*PPH1HTHSTF*
Policy Number(s)
Health Statement Form FOR OFFICE USE ONLY
Date Received: ____________
(for Rider Addition) Time Received: ____________
Important Notes: Receiving
1. This form is to be accomplished by the Policy Owner/Assignee in BLOCK LETTERS. Dept./Office: ____________
2. Please do not sign on a blank form.
3. Please put a shade in the circle to indicate your choice(s).
FOR DISTRIBUTOR’S USE ONLY
1. My General Information (MANDATORY SECTION. Please complete all fields.) FE/Advisor’s code:
__________________________
Full Name of Insured (Last Name, First Name, Middle Initial) FE/Advisor’s name:
__________________________
FE/Advisor’s mobile number:
Full Name of Policy Owner (Last Name, First Name, Middle Initial)
__________________________
Policy updates via: E-mail SMS Notification
With payment Payment Center
My current mobile no. - (09XX-XXXXXXX)
__________________________
My e-mail address Date _____________________
Residence Office Amount __________________
My other telephone nos. Without payment
2. Rider to be added and Health & Avocation Information
VARIANT
For secure rider, please answer questions 1-3
Secure - accidental death and dismemberment benefit YRT 20YRT UP TO AGE 55
5 PAY
10 PAY
For the following riders, please answer questions 1-7
Critical Conditions - critical illnesses benefit YRT 20YRT UP TO AGE 55
Economy Superior Economy Superior
Care - daily hospitalization benefit YRT Regular Premier 20YRT UP TO AGE 55 Premier
Protector - additional life insurance coverage YRT 5YRT 10YRT 20YRT
5 PAY
20 PAY
10 PAY
UP TO AGE 55
5 PAY
20 PAY
10 PAY
UP TO AGE 55
Health Max Rider - guaranteed health coverage for 56 major & 18 minor critical illnesses 20 PAY PAY TO AGE 65
Waiver of premium - waives all future premiums in case of total and permanent disability of insured
Payor’s clause - waives all future premiums in case of total and permanent disability or death of payor
Height Weight Have you experienced any weight change in the last 12 months, please
state amount gained or lost (lbs.) and the reason for weight change.
Please state the height and weight Insured __________ ft/in __________ lbs
of the Proposed Insured/Owner. Policy owner __________ ft/in __________ lbs
Insured Owner
QUESTIONS
(Owner to answer if payor’s
clause is applied for) If “yes”, please indicate details
Yes No Yes No
1. Have you ever applied for life, health, critical illness cover, accident or disability
insurance that has been declined, postponed, rated, modified or renewal refused?
Or received any claims benefit from existing cover? If yes, please provide details.
2. Are you exposed to any danger in the pursuance of your occupation or do you
intend to engage in any of the following pursuits?
• Any dangerous sports/activities (e.g. Aviation, Skydiving, parachuting,
hang gliding, motor sports, diving, climbing, caving, or scuba diving
below 45 meters)
3. Since the original policy inception date, has your occupation changed?
If yes, please state new occupation and duties.
Have you ever held or intend to be a candidate, in the coming election, in public
elective office? Please indicate position.
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Health Statement Form
Insured Owner
QUESTIONS
(Owner to answer if payor’s
clause is applied for)
If “yes”, please indicate details
Yes No Yes No
4. Do you smoke cigarettes/cigars or consume any other form of tobacco No. of cigarettes/tobacco per day: __________
(including smokeless tobacco)? No. of years smoking: _____________
(If yes, indicate no. of cigarette or tobacco sticks/day and no. of years smoking)
5. Are you currently receiving any medical treatment or do you intend seeking or have
been advised to seek medical treatment for any health problem or are you waiting
for the results of any tests/investigations? If illness is not stated below, kindly
specify the details.
• Chest pain, high blood pressure, heart attack, stroke, diabetes, any heart,
blood disorders or vascular diseases
• Cancer, melanoma, tumour/lump/polyps/ growth of any kind.
• Gastrointestinal, genitourinary, respiratory, ears, eyes, epilepsy, neurological,
psychiatric, kidney, liver, metabolic and endocrine disorders
• Joint, limb or bone conditions, auto immune diseases, infectious diseases
• Hepatitis B or C, HIV, tuberculosis, alcohol or drug dependency
• Unexplained weight loss
Have you ever seen a Doctor or other health professional, or been prescribed
medication for any other condition which has lasted for more than 5 days
(apart from usual flu and colds).
6. Has your biological mother, father, or any sister or brother been diagnosed prior to
age 60 with any inherited conditions (e.g. Cancer, Heart Attack, Stroke,
Huntington’s disease, Polycystic Kidney Disease)?
7. For Female Applicant Only No. of Months: ______________
• Are you currently pregnant? Expected delivery date: ______________
• Please indicate if with pregnancy related complications. Complications: __________________________
_______________________________________
3. Declarations and Agreement
I agree that the approval of this application is based on the truth of the above statements.
I also agree that if any of the statements above is found to be untrue in any respect and the policy has not been in force during the insured’s lifetime for at least two
(2) years from the approval date of this application, AXA Philippines shall have the right to declare such request as null and void.
I also agree that any payment made or to be made by me in connection with the application shall be considered as deposit only and shall not bind AXA Philippines in
any manner until the application is finally approved during my or the insured’s lifetime and good health. I also understood that if this application is finally disapproved,
AXA Philippines will refund any deposit without interest.
IMPORTANT: PLEASE DO NOT SIGN ON A BLANK FORM
Signed at __________________________________ this _______day of _______________________.
Signature of Insured Signature of Policy Owner
4. Certification of Customary Signature
IMPORTANT: If signature differs between AXA file and documents submitted, please complete this form.
CERTIFICATION OF CUSTOMARY SIGNATURE
This is to certify that I am the same person who signed in the policy contract. I hereby confirm that the declarations and information therein were given by
me, and I certify that they are true and complete to the best of my knowledge. Finally, the signature appearing on all the forms and valid ID/s are my
customary signatures and for which reason I have signed both with my customary signatures as follows:
1. 2. 3.
5. How do I track the status of my request
You will be updated through SMS &/or e-mail (if you choose e-notiXes) of additional requirements, if any. If you have any query on your request,
you may get in touch with your AXA distributor or reach us by:
+632 5815-AXA [Link]@[Link] chat via [Link]
AXA is committed to making your service experience as easy and stress-free as possible. Thank you for insuring with us. We are always glad to be of service.
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