LIFE INSURANCE APPLICATION

GROUP
Digital version

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DEAR SIR/MADAM, THE RECEIPT OF THIS REQUEST DOES NOT IMPLY ACCEPTANCE OF RISK. IF THIRTY (30) CALENDAR DAYS HAVE PASSED FROM
IF THE DATE OF RECEIPT OF THE APPLICATION, MAPFRE DOES NOT ISSUE THE POLICY, IT WILL BE UNDERSTOOD THAT THE APPLICATION HAS BEEN REJECTED.

TIPO DE NOVEDAD

ADVISOR NAME FILING DATE

DD MM AAAA

DATOS DEL TOMADOR

DOCUMENT TYPE NUMBER NAME OR BUSINESS NAME REQUEST DATE
DD MM AAAA

DATOS DEL ASEGURADO

LAST NAMES NAMES

DOCUMENT TYPE NUMBER GÉNERO DATE OF BIRTH MARITAL STATUS

DD MM AAAA

RESIDENTIAL ADDRESS RESIDENTIAL PHONE CITY DEPARTMENT COUNTRY

CELL PHONE NUMBER EMAIL

MONTHLY INCOME PROFESSION HEIGHT (CMS) WEIGHT (KG)

CURRENT OCCUPATION HOW MANY CIGARETTES PER DAY?Do you drink alcohol?
DO YOU SMOKE? FREQUENCY QUANTITY

Are you currently taking any medication? Which?

BENEFICIARIES OF THE INSURED

TYPE OF DOCUMENT No. DOCUMENT GÉNERO LAST NAMES NAMES % Relationship

0%

Health Background
Haveyousufferedfromorbeendiagnosedwithanyofthefollowingdiseases?(Ifyes,pleasefillouttheadditionalfields)
DIAGNOSIS DATE, OCCURRENCE OR
TYPE OF DISEASE YES/NO TREATMENT / EVOLUTION PRACTICE CURRENT STATUS
DD MM AAAA

Cardiovascular
Hypertension
Pulmonary,asthma,tuberculosis
Digestive(ulcers,polyps,cysts,hernias,
colon)
Renal and/or genitourinary (prostate,
testicles, uterus, ovaries, fallopian tubes
Liver diseases (liver, pancreas)
Venereal diseases
Musculoskeletal, rheumatism, arthritis

Mental (bipolarity,Alzheimer's, depression…)

Nervous (epilepsy, emotional disorders...)

Diabetes mellitus
Cancer or other tumors
Cerebrovascular
AIDS / HIV

Have you had any accidents or serious injuries?

Deformities or malformations
Another disease not previously described?
Which?
Have you been hospitalized in the last 5
years?
Have you undergone surgeries in the last
10years?
Are you thinking of undergoing any surgery?

WOMEN
Are you pregnant? MY EXPECTED MONTH OF DELIVERY

Gynecological or obstetric complications? Which ones?

Have you had previous pregnancies? Have I had complications during those deliveries? Which ones?
 COVERAGES AND INSURED AMOUNTS
DEATH DUE TO TOTAL DISABILITY AND
ACCIDENTAL DEATH SERIOUS DISEASES Funeral DAILY RENT FOR HOSPITALIZATION
ANY CAUSE PERMANENT
INSURED VALUE

INTERMEDIARY DATA
INTERMEDIARY NAME KEY BRANCH

I reiterate that what is stated in this declaration is true and that the answers I provide to the doctor who examines me, depending on the case, and those indicated in the health declaration, will serve as the basis for the issuance of the insurance policy.
modification of the same and in which MAPFRE assumes no responsibility, except through the issuance of the policy or certificate or modification prior to payment of the premium provided that I am in good health at that time. If I am
I will check at any time that there has been an error, falsehood, omission or reticence on my part in such statements that, if known by MAPFRE, would have led them to reject the risk, reduce its amount or charge a premium.
higher than the initially quoted, I accept the cancellation of the policy or the reduction of its value at the Insurer's choice.

[Link].

In accordance with the provisions ofArticle 34 of Law 23 of 1981 and such regulations, I authorize MAPFRE, to request and receive from any service provider starting from the signing of this application and even after my death.
of health that has attended to me, a copy of my medical history and of all those who are recorded in it or may be recorded and of its annexes. In the same way, I expressly authorize to request from any person or entity,
financial, commercial and personal information, and/or to confirm the databases of insurance for individuals with aggravated risks and compensations.
It will be the obligation of the Policyholder to inform the insured about the General Conditions of this policy. The Insurer fulfills the obligation of article 1046 of the Commercial Code by delivering the Conditions to the Policyholder.
It is the responsibility of each Insured to inform themselves about the specific conditions of the product and to express any doubts they may have in a timely manner and through the appropriate means.

DECLARATIONS AND AUTHORIZATIONS FOR THE PROCESSING OF PERSONAL DATA

DEFINITIONS

Companies mean the entities MAPFRE SEGUROS GENERALES DE COLOMBIA S.A. and MAPFRE COLOMBIA VIDA SEGUROS S.A. Group Company means any legal entity that directly controls, is controlled by, or is under control.
common of the Companies, including but not limited to CREDIMAPFRE S.A., MAPFRE SERVICIOS EXEQUIALES SAS, ANDIASISTENCIA S.A., CESVICOLOMBIA S.A. Treating Companies mean the Companies, the Group Companies, the Third Companies and
any other entity that processes My Personal Data in accordance with this document. My Personal Data means any or all Personal Data (as understood under the applicable legislation) that I have provided.
prior to the Treating Companies, which I provide with this document, that I deliver in the future or that the Treating Companies receive in accordance with this document for their Treatment, including my Sensitive Personal Data, such
such as health data and biometric data. Third Parties means the companies to which the Company or any of the Group Companies provide My Personal Data by virtue of the authorizations I grant in this document,
including: (i) Those who act as Data Controllers; (ii)Any insurance intermediary of the Treating Companies; (iii)Any company with which the Companies or Group Companies have entered into contracts
to support the provision of its services or the offering, sale or support of its services and/or products or complementary products and/or services, such as researchers, adjusters, assistance companies, external lawyers, channels
commercial, professional services, etc.; (iv) Operators, in the sense that this word has under law 1266 of 2008; and (v) Fasecolda and Inverfas S.A. for the purposes of fulfilling their union and legal obligations.

STATEMENTS

I declare and guarantee that (A) I have been informed of my rights as the owner of My Personal Data, which include the following: (i) To know, update, and rectify My Personal Data in front of the Processing Companies; (ii) To request
proof of this or any other authorizations I may have given for My Personal Data; (iii) Upon request, to be informed about the use that has been made of My Personal Data by the Processing Companies; (iv) To present before the competent authority
complaints for violations of the personal data protection regime; (v) Request the deletion of My Personal Data or the revocation of my authorization when the competent authority has sanctioned the Processing Companies for conduct
illegal in relation to My Personal Data; (vi)Access My Personal Data for free. (B) I know the optional nature of the responses to questions about My Sensitive Personal Data or about children and adolescents. (C)
I am aware of the identifications, physical and electronic addresses, and the phone numbers of the Companies and the Group Companies that act as Data Controllers in relation to My Personal Data, which are included in the header of this.
document. (D) I know and accept that the non-delivery or authorization of My Personal Data may prevent the provision of services by the Treating Companies and therefore lead to the termination of contracts with the Treating Companies.
I have all the necessary authorizations to provide the Processing Companies with the Personal Data of third parties (such as insured parties, beneficiaries, etc.) that I have provided or will provide for their Processing.

AUTHORISATIONS
I grant my express, explicit, and informed authorization to the Companies and the Processing Companies to carry out any processing operation on My Personal Data (including those collected or processed prior to this)
document for the Treating Companies) with the following purposes: (i) Process my application as a financial consumer, debtor, contractual counterparty, and/or supplier; (ii) Negotiate and enter into contracts with the Treating Companies, including the
determination and analysis of premiums and risks, and execute them (including sending correspondence); (iii) Execute and fulfill the contracts that the Companies enter into with entities in Colombia or abroad to carry out their activity
insurance company and the services I contracted, including co-insurance and reinsurance activities; (iv) The control and prevention of fraud, money laundering, terrorist financing or the financing of the proliferation of weapons of mass destruction;
(v) Determine and settle claims payments; (vi) Monitor compliance with requirements related to the Comprehensive Social Security System; (vii) Prepare technical-actuarial studies, surveys, market trend analyses, and in general
any technical or field study related to the insurance sector or the provision of services by the Treating Companies; (viii) That the Treating Companies send me offers of their products or services or commercial communications of
any class related to them, through any means of communication, including but not limited to offers of products and services from Third Parties; (ix) That the Processing Companies consult, obtain, update and/or
disclose to credit risk centers or operators of databases of financial, credit, commercial, service information and that coming from third countries or similar entities any information about the birth, the
modification, compliance or non-compliance and/or the extinction of the obligations that I may contract with the Company or with any other of the Treating Companies in order for these centers or operators and the entities to them
affiliates consult, analyze and use this information for their legal or contractual purposes, including the generation of individual and collective credit behavior profiles and others, the conducting of studies and activities
commercial; (x) Create databases according to the characteristics and profiles of the Data Subject holders; and (xi) Sending financial information of taxpayers in the United States to the IRS or other authorities in the United States.
other countries, in terms of FATCAor similar nature regulations of third countries or international treaties.

I grant my express and informed authorization to the Companies and the Group Companies for my Personal Data to be transferred, transmitted, and processed by Third Companies. The Processing Companies may be located in Colombia.
or abroad, even in countries that do not provide adequate levels of data protection.

DURATION OF THE PROCESSING OF MY PERSONAL DATA

The Treating Companies may Process and retain My Personal Data as long as necessary for the fulfillment of any obligation between the Treating Companies and/or the handling of any judicial or extrajudicial complaint or claim.
01042020-1326/1430-P-34-VTE01ABR2020

INSURED NAME

IDENTIFICATION OF THE POLICYHOLDER