2 02 PDF

Policy Number
511 - 1806153
Application Number R 39803-201907120719-2-02
Traditional Variable Multiple Application

Application for Life Insurance of
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).
1. DETAILS OF PROPOSED INSURED
LAST NAME
REBUYON
FIRST NAME Notes
KID ERNEST JONES Please accomplish as

well the “Proposed Owner
MIDDLE NAME Details” section at the
back page if the Proposed
Owner is different from
MADAYAG the Proposed Insured.
DATE OF BIRTH(YYYY/MM/DD) PLACE OF BIRTH Politically Exposed Person (PEP)

SEX CIVIL STATUS
is an individual who is or has
KORONADAL CITY Male Female
1997/02/23 Single Married Widow Divorced/Annulled been entrusted with prominent
public positions in the Philippines
with substantial authority over
policy, operations, or the use or
allocation of government-owned
NATURE OF OCCUPATION/BUSINESS SPECIFIC OCCUPATION IDENTITY NO. (TIN, SSS or GSIS) resources; or a foreign state or
ADMINISTRATIVE ASSISTANT II Office Employee/Staff Other: 011-1873-6368-5 international organization,
including heads of state or of
NATIONALITY government, senior politicians,
senior national, or local
ARE YOU AND/OR YOUR IMMEDIATE FAMILY A POLITICALLY EXPOSED PERSON (PEP)? Yes No Philippines government, judicial or military
(If yes, please specify government position/public office)
officials, senior executives of
government or state-owned or
IF WORKING ABROAD, STATE THE CITY/PROVINCE AND COUNTRY controlled corporations and
important political party
RESIDENCE/PRESENT ADDRESS officials.
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province)
ZIP CODE
BLK. 1 LOT 15 DONA LOURDES SUB BARANGAY ZONE II KORONADAL CITY SOUTH COTABATO
9506
Residence Address should
be a Philippine Address
PERMANENT ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS) (in reference to
Cross-Border Rule)
ZIP CODE
Residence Address shall
BLK. 1 LOT 15 DONA LOURDES SUB BARANGAY ZONE II KORONADAL CITY SOUTH COTABATO
9506 be used as default mailing
address
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
PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business
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
Maturing Investment/Php Others: 15000.00
IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX RESIDENT? No Yes US TIN/SSN:

(If yes, please provide US TIN/SSN)
MAMRXXEXREG-1118 1 of 23
Application for Life Insurance Application Number R 39803-201907120719-2-02
2. DETAILS OF PROPOSED OWNER (If different from Proposed Insured)
LAST NAME
Notes
FIRST NAME Accomplish only if

Proposed Owner is
different from Proposed
Insured.
MIDDLE NAME
Politically Exposed Person
(PEP)
is an individual who is or has been
DATE OF BIRTH(YYYY/MM/DD) PLACE OF BIRTH entrusted with prominent public
SEX CIVIL STATUS positions in the Philippines with
substantial authority over policy,
Male Female Single Married Widow Divorced/Annulled operations, or the use or allocation
of government-owned resources;
or a foreign state or international
organization, including heads of
state or of government, senior
NATURE OF OCCUPATION/BUSINESS SPECIFIC OCCUPATION IDENTITY NO. (TIN, SSS or GSIS) politicians, senior national, or
local government, judicial or
military officials, senior executives
of government or state-owned or
NATIONALITY controlled corporations and
important political party officials.
ARE YOU AND/OR YOUR IMMEDIATE FAMILY A POLITICALLY EXPOSED PERSON (PEP)? Yes No
(If yes, please specify government position/public office)
IF WORKING ABROAD, STATE THE CITY PROVINCE AND COUNTRY

RESIDENCE/PRESENT ADDRESS
(Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE
Residence Address should be

a Philippine Address
(in reference to
Cross-Border Rule)
PERMANENT ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)
ZIP CODE Residence Address shall
be used as default mailing
address
BUSINESS ADDRESS
BUSINESS NAME/NAME OF EMPLOYER (Please include Unit/Floor Number, Building Name, Street, Barangay, City, Province) ZIP CODE
PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business
CONTACT INFORMATION
HOME PHONE NUMBER MOBILE NUMBER (Mandatory)
BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

The Contingent Owner will
automatically become the
new Owner of this policy in
the event that the Owner
RELATIONSHIP OF PROPOSED OWNER CONTINGENT OWNER UPON DEATH OF RELATIONSHIP OF CONTINGENT OWNER
predeceases the Insured
TO PROPOSED INSURED OWNER TO PROPOSED INSURED while this Policy is in force.
If the owner has not
appointed a Contingent
Owner, the Insured shall
automatically become the
SOURCE OF FUNDS/MONTHLY INCOME new Owner of this Policy in
the event that the Owner
Salaries/Php Income from business/Php predeceases the Insured
Savings/Php while the policy is in force.
Maturing Investment/Php Others: Designation of a
minor as Contingent Owner
is discouraged.
IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX RESIDENT? No Yes US TIN/SSN:
(If yes, please provide US TIN/SSN)
BENEFICIAL OWNER (If any)

Beneficial Owner refers to
the owner/controller of the
policy owner as well as to
the beneficiary to the policy
contract. It also refers to a
Full name, Present address, Date and place of birth, Nature of work, Sources of funds natural person who
ultimately owns or controls
the account and/or the
3. DETAILS OF THE COMPANY (IF OWNER IS COMPANY) person on whose behalf a
transaction or activity is
being conducted. It also
includes those persons who
FULL BUSINESS/COMPANY NAME FULL NAME OF AUTHORIZED SIGNATORY has ultimate effective
control over a legal person
or arrangement.
NATURE OF BUSINESS FULL NAME OF AUTHORIZED SIGNATORY
*Authorized signatory/ies will be asked to provide required additional information
CONTACT INFORMATION OF AUTHORIZED SIGNATORY

MOBILE NUMBER (Mandatory) BUSINESS ADDRESS
BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)
4. BENEFICIARY DESIGNATION Notes
*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
Secure (AD&D) Critical Illness Protector (Term)

RIDER SUM INSURED RIDER SUM INSURED RIDER SUM INSURED
YRT 20YRT UP TO AGE 55 YRT 20YRT UP TO AGE 55 YRT 5YRT 10YRT
5 PAY 10 PAY 20YRT UP TO AGE 55
5 PAY 10 PAY 5 PAY 10 PAY
20 PAY 20 PAY UP TO AGE 55

Selection of “Waiver of
Premium” or “Payor’s
Clause” as policy
Waiver of Premium Care (Hospital Income) YRT 20YRT UP TO AGE 55 supplement applies
to the basic and
Economy Superior Economy Superior Premier supplement riders
Payor's Clause Regular Premier where it is applicable
Others Rider Name Rider Sum Insured
Rider Name Rider Sum Insured Applicable only for term

products with conversion
provisions.
7. CONVERSION OF TERM INSURANCE

Billing cycle: policies with
Conversion of Term Insurance is when all or some of your term life insurance policy or rider/s are converted into a permanent life insurance policy or rider/s. 1-15 as Effective Date shall be
charged every 5th of the
* For Individual, Basic Term or Term rider plans month while those with
Policy No*./Certificate No**. 16-28 as Effective Date
** For Group Term plans shall be charged every 20th of
the month. For rejected
billings due to insufficient
balance, we will initiate
rebilling efforts in an
8. PAYMENT INSTRUCTIONS objective to keep your
policy in-force.
MODE OF PAYMENT METHOD OF PAYMENT
Policies with IIE feature and
Annual Semi-annual Auto-Debit Arrangement (ADA) Credit Card Cash enrolled in ADA/CC
will automatically be charged
Quarterly Monthly Post Dated Check (PDC) Initial premium Recurring Others: with the applicable IIE
premium on the 2nd policy
year.
(for Traditional
9. DIVIDENDS/ENDOWMENTS AND PREMIUM DEFAULT OPTIONS products only) Requests for cancellation of
ADA/CC payments should
be submitted 30 days prior to
* DIVIDEND/ENDOWMENTS OPTIONS ** PREMIUM PAYMENT DEFAULT OPTION the scheduled debit/ charge
date.
Accumulate with Interest Extended Term Insurance (ETI)
Requests for PDC pull-out
Apply to premiums Reduced Paid Up (RPU) should be received at least
5 working days before the
Pay in cash Automatic Premium Loan (APL)
check maturity date.
Credit card payment is

* By default, if no Dividend/Endowment Options is selected, below ** By default, if no Premium Option is selected, below will apply: NOT allowed for Single
will apply: Accumulate with Interest ETI – for standard cases; RPU – for substandard cases Premium policies
All fund allocations

should total to 100%
10. DETAILS FOR VARIABLE INSURANCE

TOP-UP OPTIONS, If applicable DEATH BENEFIT OPTIONS, If applicable
Regular Annual Top-Up Level Increasing
Lump Sum Top-up Amount
FUND NAME % ALLOCATION FUND NAME % ALLOCATION
1. Philippine Wealth Equity Fund 30 4.
2. Opportunity Fund 10 5.
3. Chinese Tycoon Fund 60 6.
11. DECLARATION OF PROPOSED INSURED and OWNER (If Payor’s Clause is applied for)
Proposed Insured Proposed Owner If "Yes", please

Other Insurance and Lifestyle Questions (Owner to answer if payor’s clause indicate details
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
5. Do you participate or intend to participate in any hazardous activities

related to your occupation or any recreational activities such as (but not Yes No Yes No
limited to): scuba diving, mountaineering or climbing, skydiving,
parachuting, hang-gliding, motor sports or aviation (excluding flying as a
passenger on a regular scheduled airline)?
6. Have you ever taken any habit forming drugs or narcotics, or been
Yes No Yes No
treated or counselled for a drug problem?
7. Do you consume alcoholic beverages? If yes, give type and number of Yes No Yes No
drinks per day and/or per week.
Have you smoked or used any of the following in the last twelve
8.
months?:
a. Cigarettes Yes No Yes No PI PO
b. e-cigarettes Yes No Yes No sticks/day
c. Vape Yes No Yes No no. of packets/day
d. Smokeless tobacco Yes No Yes No months/years
e. Never smoked Yes No Yes No ml per day (for vaping)
Medical Questions
1. Height 5'4"(ft. & in.) or 162(cm.) and weight 149lbs. or 67.5853kg.

a.Have you experienced any weight change in the last 12 months? If yes, please state Yes No Yes No
amount gained or lost (kg) and the reason for weight change.
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.
b. Cancer (including melanoma), tumor or growth of any kind. Yes No Yes No
c. Diabetes, thyroid disease, metabolic or endocrine diseases. Yes No Yes No
d. Hepatitis B or C (including Hepatitis carrier), HIV infection, liver, Yes No Yes No

gallbladder, or any gastrointestinal diseases.
e. Kidney diseases, diseases of the genitourinary system, breast diseases, Yes No Yes No
or any reproductive organ diseases.
f. Any musculoskeletal diseases (including joint/bone diseases, arthritis) Yes No Yes No

or any auto-immune diseases (including lupus).
g. Eyes/ears/nose/throat diseases, or any respiratory diseases. Yes No Yes No
h. Epilepsy, head/brain injury, paralysis, psychiatric diseases or other Yes No Yes No

neurological 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)?
4. Are you currently receiving any medical treatment or intend seeking or

have been advised by a physician to seek medical treatment for any
Yes No Yes No
health conditions or waiting the results of any medical
tests/investigations?
5. Have your biological mother, father, brother(s) or sister(s) been

Please refer to Second Level
diagnosed, before age 60, with any of the following: cancer, heart Yes No Yes No
Answers
disease, stroke, diabetes or any other inherited conditions?
For Female Applicant Only
1. Are you currently pregnant? Yes No Yes No
If yes, how many months?
Expected delivery date
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.
12. REPLACEMENT OF EXISTING LIFE INSURANCE POLICIES
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
13. DECLARATIONS AND AGREEMENT:

I/WE UNDERSTAND, DECLARE AND AGREE THAT:
1. Before signing this Application, I/we have read the same carefully and the questions were fully explained to me/us in a language/dialect which I/we understand. 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.
2. The answers or statements made in this Application and those that I/we made in the Full Medical Report and any other document attached thereto, are complete, true
and correctly recorded and shall form part of and be the basis of the insurance contract herein applied for. Failure to make a full disclosure renders the contract
voidable.
3. I/We understand that the designated Contingent Owner (if any) will automatically become the new Owner of this policy or in the event that I/we have not designated
a Contingent Owner, I/we understand that the Insured shall automatically become the new Owner of the Policy in the event that the Owner predeceases the Insured
while the Policy is inforce.
4. I/We declare that I/we am/are aware of the consequences of a minor beneficiary designation as follows: (a) that a minor, if designated irrevocable, is still unable to
give a valid consent to any transaction on the policy; where such consent is required, the minor would need representation by a guardian appointed by the court when
transactions like policy loan, surrender, changes in benefit, etc. are applied for under the policy: (b) when a death claim is filed under the policy, whether the minor is
a revocable or irrevocable beneficiary, a court appointed guardian and guardian’s bond may be required.
5. All the information I/we provided on this application form are to the best of my knowledge true and correct.
6. Any of my/our personal information collected or held by AXA Philippines (whether contained in the application/s or otherwise), may be used in connection with
matching for whatever purpose with such other personal information and/or may be used, stored, disclosed, transferred (whether within or outside the Philippines) to
such persons as AXA Philippines may consider necessary, including without limitation but not limited to any of its affiliated or related companies, or any
individuals/organizations/corporations/entities associated with AXA Philippines:
a. to process and deal with my application/policy;
b. to provide all services related to my application/policy, to promote other products/services by AXA Philippines and its affiliated or related
companies/entities, and to process my information for product development and for marketing purposes;
c. to communicate with me for any purpose and/or to comply with the laws of any applicable jurisdiction.
I/We understand that we have the right to access our personal information at any time; correct or rectify any information collected or held by AXA Philippines which
are inaccurate, false, or incomplete; object in case of any unauthorized collection; erase or block information which is incomplete, outdated and false; and such other
rights as may be available under the Data Privacy Act.
7. I/We understand that AXA Philippines shall use my/our personal information to evaluate and assess my/our application and need for life insurance and investments,
as well as to service any of my/our policies and needs including the evaluation of any future claims. I/We also authorize AXA Philippines to disclose to any person or
entities providing services on AXA’s behalf consistent with the purpose for which the information was obtained.
8. I understand that notices related to my policy may be sent to me through mail, email or SMS in the mailing/email address/number I provided above.
9. I/We declare that I/we have informed AXA Philippines of all my/our citizenships, residencies and tax residencies, and provided AXA Philippines with my/our
TIN, GSIS or SSS number(s). I/We agree to promptly update AXA Philippines of any changes to said information. I/We authorize AXA Philippines to disclose my/our
personal information to any government or tax authority (within or outside the Philippines) for the purposes of ensuring AXA’s compliance with applicable laws and
regulations.
I/We agree that AXA Philippines shall have the right to: (a) require the claimant(s) and/or payee(s) of the Policy to provide AXA Philippines with their above-
mentioned personal information and/or sign such documents as AXA Philippines may reasonably require; (b) and disclose said personal information to any
government or tax authority (whether within or out of the Philippines) for the purposes of AXA's compliance with applicable laws and regulations. If I/we fail to any
of the above-mentioned acts, I/we agree that AXA Philippines may provide my/our personal information to such government or taxation authority(ies) to comply
with the applicable laws and regulations.
10. The amounts invested have been declared to relevant tax authorities and none of it was derived, directly or indirectly, from illegal activities or sources and/or tax
evasion. If required by the proper tax and/or other governmental authorities, AXA Philippines may, in its discretion, disclose certain information about me/us or
about my policy.
11. I/We hereby authorize any person, physician, clinic, hospital, insurance company, or other organization, insurance association, institution, that has any record or
knowledge of my/our health and/or financial information to disclose or release to AXA Philippines or its authorized companies and their affiliates any medical
information sharing facility of the insurance industry, or any government agency requiring such, for any legitimate purpose, including underwriting and
administration of insurance coverage and claims.
12. I/We authorize AXA Philippines to request and obtain from third parties, whether government agencies or private entities, any information concerning me/us
relevant to this application, including medical or financial information.
13. There shall be no contract of insurance unless and until a policy is issued on this Application and the full first premium of the basic life insurance and any special
benefit applied for, according to the mode of payment specified in answer to Part 7, is actually paid during the lifetime and good health of the Proposed Insured.
14. I/We have read and fully understood the Life Insurance Proposal (or the illustration of benefits) for the policy applied for.
15. An electronic copy of this application shall be binding to me/us and shall be considered, for all intents and purposes, as originally signed document. I/We will inform
the Company of any inaccuracy or error in my/our personal data as soon as possible, and I/we understand that absent any request for correction within a reasonable
period, the Company shall rely on the electronic copy exclusively.
An electronic copy of the policy contract shall be sent to the Owner’s declared email address by default. Upon request and payment of reasonable fee, a hard copy of
the policy contract may be delivered to the nearest AXA Philippines Service Center for pick up by the Owner or his/her representative or directly to the Owner’s
mailing address, whichever is preferred.
My/Our electronic submissions shall constitute my/our intention to apply for this Policy and be bound by the terms and conditions relating to all transactions
undertaken, including but not limited to receipt of notices, presentation and purchase.
16. I/We understand that Inflation Index Endorsement (IIE), if included in the Life Insurance Proposal, will be applied at each Policy Anniversary. I further understand
that IIE means that with no further proof of insurability and with a minimal additional premium, my insurance protection will be increased to ensure that the basic
sum insured will be maintained against inflation. I/ We also understand that I can choose not to avail of IIE by informing the Company via email, call or advise
through my/our distributor.
17. Other agreements pertaining to Variable Life Insurance products:
a. My/Our Fund Allocation instruction, if applicable, is based on my/our own judgment and I/we have not relied on any advice provided by the
Advisor/FE;
b. I/We am/are fully aware that, if applicable, relevant policy charges, e.g. bid-offer spread, premium charge, asset management charge, will be imposed
on the policy that will be issued;

c. I/We fully understand that a variable life insurance product involves risk. Value of units in Investment Funds may rise or fall. The benefits payable
under such product are linked to the performance of the Investment Funds according to my Fund Allocation Instruction;
d. I/We fully understand that if this application is cancelled by written notice, signed and sent by me/us directly to and received by the New Business and
Underwriting Department of AXA Philippines before it is approved, I/we can refund all the premium deposits paid by me/us and received by AXA
Philippines. If such notice is received by the New Business and Underwriting Department of AXA Philippines after the application is approved, the
amount of refund shall be equal to the market value of its units including initial charges; and
e. I/We understand that I have the right to cancel the policy to be issued during the cooling-off period provided therein and obtain a refund equal to the
market value of units including the initial charges thereof by giving a written notice and returning the policy. Such notice must be signed and sent by
me/us directly to and received by Customer Experience of AXA Philippines within 15 days from my/our receipt of the policy.
18. In the event of the Insured’s death prior to his/her attaining the age of four (4) years and six (6) months:
a. the amount payable under the Policy shall be in accordance with the following schedule:
Age at Death Amount Payable (Variable Life Policy) Death Benefit Payable
(nearest birthday) (Traditional Life Policy)
Less than 6 months 50% of the Sum Insured, or the Account Value, whichever is higher 50% of the Sum Insured
1 year 60% of the Sum Insured, or the Account Value, whichever is higher 60% of the Sum Insured
2 years 70% of the Sum Insured, or the Account Value, whichever is higher 70% of the Sum Insured
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.
14. TELEPHONE UNDERWRITING AUTHORIZATION

I/We, hereby permit AXA Philippines to call me/us to clarify or gain further information regarding any matter pertaining to the assessment and processing
of my/our application for life insurance.
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.
During office hours (8 am-5 pm) Others, please specify
15. REQUEST FOR DIRECT CREDIT TO BANK ACCOUNT
Policy No.: Account type: Bank Name:
Peso account Dollar account Metrobank Others:
Branch Name: Swift Code (for Non-Metrobank) Account Number of payee:
Account Name of payee: Relationship to owner
Spouse Child Parent Sibling
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.
**PLEASE DO NOT SIGN ON A BLANK FORM
Date of Signing: Place of Signing:
KID ERNEST JONES REBUYON

Signature (Proposed Insured) Signature (Proposed Owner)
**(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.
Name of Advisor/FE: DOMIDER, DERWIN BAUTISTA Name of Advisor/FE:
Code: Code:
212020 4 39803
Signature: Signature:
16. DISTRIBUTOR’S DECLARATION
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.
Name of Advisor/FE: DOMIDER, DERWIN BAUTISTA Name of Advisor/FE
Signature: Signature:
17. CREDIT CARD AUTHORIZATION/AUTO-CHARGE ENROLLMENT
Please refer to the back page for the Declaration and Reminders of this application form
CURRENCY: PHP USD ONE-TIME CHARGE RECURRING PREMIUMS* Date:

*Succeeding premiums due will be automatically charged to the enrolled card no.
Account type: Visa Mastercard

Month Year
Credit Card Number Expiry date: /

Credit Card Company: Billing Address:
Cardholder's Name:
(Last Name) (First Name) (Middle Name)
Cardholder's Birthday: Name of Insured(s):
Mother's Maiden Name:
Contact Number(s) of
Cardholder:
Relationship of card holder to Owner of policy
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.
Application Number R39803-201907120719-2-02
TEMPORARY LIFE INSURANCE CERTIFICATE

There is temporary insurance on the life to be insured beginning on the date of signing by the Proposed Insured/Owner of the Application form bearing the same serial
number as this certificate, if all the following conditions are met: (1.) The first modal premium has been paid with the Application for which a Temporary Receipt is
issued; (2.) Questions stated on section no. 10 were answered “NO” and (3.) All other required questions of the Application form are answered completely and
truthfully. All conditions under this certificate are subject to the Provisions of the Policy the Proposed Insured and/or Owner has applied for.
LIMITATION ON AMOUNT OF INSURANCE
The insurance benefit on the death of the life insured pursuant to this certificate is the amount which AXA Philippines would have paid had the Policy applied for been
issued. AXA Philippines shall in no event pay, subject to the imposition of juvenile lien whenever applicable, no more than One Million Pesos (PhP1,000,000) or the
equivalent in US Dollars, based on the prevailing exchange rate at the time of death of the Proposed Insured. The maximum amount of PhP1,000,000 includes any
accidental death benefit, under all Temporary Life Insurance Certificates inforce in respect of the Proposed Insured. However, if the insurance benefit paid for by the
Proposed Insured exceeds the said maximum, the amount of excess premium, which will be determined proportionately to the Policy applied for, will be refunded. The
insurance benefit will be prorated among all the Temporary Life Insurance Certificates inforce on that Proposed Insured.
TERMINATION OF TEMPORARY LIFE INSURANCE COVERAGE ON THE LIFE INSURED WILL BE THE NEAREST OF THE FOLLOWING:
(a) The date a termination notice is sent by AXA Philippines to the Applicant;
(b) The date the policy is issued as a result of the Application being approved;
(c) The date of termination as requested by the Applicant;
(d) The date of death of the Proposed Insured; and
(e) Sixty (60) days after signing this Application.
SUICIDE: If the life insured dies by suicide, the pertinent provisions of the Insurance Code shall apply. Where no insurance money is payable, the amount paid with
the Application will be refunded. No Advisor/Financial Executive has the authority to modify the terms of this Certificate.
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.
Second Level Answers Reference Number: 39803-201907120719-2-02
Proposed Insured : REBUYON, KID ERNEST JONES MADAYAG
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:
Yes
before age 60, with STROKE?
Please indicate number of affected relatives diagnosed with Stroke before age 60: 1 first degree relative
Yes
before age 60, with DIABETES?
Please indicate number of affected relatives diagnosed with Diabetes before age
1 first degree relative
60:
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
Dear KID ERNEST JONES,
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)
When insured reaches age 65 Upon death of the Insured

Based on (PHP) Based on 8.00% annual rate (PHP)
4.00% annual rate of return, Account Value 1,359,874 Age 50 1,151,003
Or 8.00% annual rate of return, Account Value 4,029,524 Age 60 2,686,790
Age 70 6,002,441
Or 10.00%annual rate of return, Account Value 7,190,720
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.
Page 13 of 23 of Proposal No. 39803-201907120719-2-02

Printed on: 8/29/2019 6:32:25 PM Created on: 07/12/2019 Expiry Date: 09/10/2019
Version Number: 4.4.0 Date for Next Insurance Age: 08/24/2020
Plan Code: BAX/ Rider Code: N/A
Philippine Peso
for: Mr. KID ERNEST JONES MADAYAG REBUYON, 23, Male, Non-
smoker
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.
DOMIDER, DERWIN BAUTISTA

212020
39803
639177134545

Philippine Peso
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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
You may also pay your premium in the following modes:

Modes of Payment Modal Premium Fund Name ³ Fund Allocation
(PHP)
Semi-Annual 7,382.00 Chinese Tycoon Fund 60%
Quarterly 3,691.00 Philippine Wealth Equity Fund 30%
Monthly 1,230.34 Opportunity Fund 10%
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.

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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
Age60 561,032 1,058,074 1,058,074 2,686,790 2,686,790 4,411,031 4,411,031

Age65 634,852 1,359,874 1,359,874 4,029,524 4,029,524 7,190,720 7,190,720
Age70 708,672 1,727,060 1,727,060 6,002,441 6,002,441 11,667,438 11,667,438
The rates of return shown above are for illustration purposes and are not based on past performance nor guarantee future performance. The actual
return may differ. The illustrated values are net of premium charges of 35%/35%/35%/35%/35% of the basic premium for the 1st to 5th policy years; all top-ups
shall be subject to a premium charge of 2%; Cost of Insurance has been deducted monthly from the illustrated values as well as Administration Charge amounting
to Php1,200 p.a. The Annual Premiums for any attached Supplement shall be deducted monthly from the illustrated values if the Policy is under Premium Holiday.
An Asset Management Charge of 2% p.a. for Philippine Wealth Bond, Philippine Wealth Balanced and Philippine Wealth Equity Funds and 2.5% p.a. for
Opportunity, Chinese Tycoon and Spanish American Legacy Funds have already been deducted from the illustrated values. The illustrated values are still
subject to a surrender charge for withdrawals (partial or full) transacted up to the 5th policy year. The surrender charge is equal to the amount withdrawn multiplied
by a surrender factor of 100%/100%/25%/10%/5% for the 1st to 5th years respectively.
This illustration shall form part of the insurance contract once the Policy is issued.

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ILLUSTRATION OF BENEFITS (with Premium Holiday on Year [PremiumHolidayYear])

You can choose to suspend payment for regular premium and top-ups as long as the Account Value of your Policy is sufficient to cover
the charges and pay for the premium of any supplement. This feature is called a Premium Holiday which you can apply for. Note that
under this feature, there is a possibility that your Account Value may be depleted and may result to your policy being terminated.
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.
Total Cumulative ILLUSTRATION OF BENEFITS (with Premium Holiday on Year [PremiumHolidayYear])

End of Regular Basic 4.00 % Rate of Return 8.00 % Rate of Return 10.00 % Rate of Return
Policy Premium, Rider
Year Premiums and Top Living Benefit Death Benefit Living Benefit Death Benefit Living Benefit Death Benefit
-up, if 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
15 147,640 139,573 400,000 210,324 400,000 257,409 400,000
20 147,640 159,701 400,000 299,427 400,000 405,614 405,614
25 147,640 190,549 400,000 446,281 446,281 665,644 665,644
30 147,640 219,183 400,000 648,391 648,391 1,064,309 1,064,309
35 147,640 252,247 400,000 945,358 945,358 1,706,363 1,706,363
40 147,640 290,833 400,000 1,381,699 1,381,699 2,740,398 2,740,398
45 147,640 337,321 400,000 2,022,828 2,022,828 4,405,721 4,405,721
50 147,640 397,756 400,000 2,964,857 2,964,857 7,087,740 7,087,740
55 147,640 477,277 477,277 4,349,007 4,349,007 11,407,159 11,407,159
60 147,640 574,040 574,040 6,382,776 6,382,776 18,363,627 18,363,627
Age60 147,640 274,610 400,000 1,186,816 1,186,816 2,266,985 2,266,985

Age65 147,640 317,537 400,000 1,736,481 1,736,481 3,643,285 3,643,285
Age70 147,640 371,219 400,000 2,544,119 2,544,119 5,859,830 5,859,830
The rates of return shown above are for illustration purposes and are not based on past performance nor guarantee future performance. The actual
return may differ. The illustrated values are net of premium charges of 35%/35%/35%/35%/35% of the basic premium for the 1st to 5th policy years; all top-ups
shall be subject to a premium charge of 2%; Cost of Insurance has been deducted monthly from the illustrated values as well as Administration Charge amounting
to Php1,200 p.a. The Annual Premiums for any attached Supplement shall be deducted monthly from the illustrated values if the Policy is under Premium Holiday.
An Asset Management Charge of 2% p.a. for Philippine Wealth Bond, Philippine Wealth Balanced and Philippine Wealth Equity Funds and 2.5% p.a. for
Opportunity, Chinese Tycoon and Spanish American Legacy Funds have already been deducted from the illustrated values. The illustrated values are still
subject to a surrender charge for withdrawals (partial or full) transacted up to the 5th policy year. The surrender charge is equal to the amount withdrawn multiplied
by a surrender factor of 100%/100%/25%/10%/5% for the 1st to 5th years respectively.
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.

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Notes on the illustration of Benefits

1. All payments and benefits shown are in Philippine pesos. Payments are acceptable in policy currency only.
2. AXA Philippines reserves the right to adjust the Basic and Supplement premiums, and any charges in this plan.
3. The quoted values are illustrations only of the key features, benefits and assumptions of the chosen insurance plans. If your
application is accepted, you will receive a policy contract, which will include detailed terms, conditions, and exclusions. A new
Illustration of Benefits will be provided in the contract, which may differ from this proposed illustration.
4. The benefits and premiums of the Index-linked Increase Endorsement, if any, are not included in the summary in the previous page.
5. The benefits are based on the projected performance of your chosen fund/s. Since 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 4.00.00%, 8.00.00%, and 10.00.00%. These rates are for illustration purposes
only and do not represent maximum or minimum return on your fund value.
6. A bid-offer spread, which is the difference between the bid price and the offer price units, may be determined by AXA Philippines from
time to time. The above illustration is based on a bid-offer spread of 5%.
7. This illustration summary relates to your Life BasiX only, and excludes any Supplements in this proposal. It assumes that all premiums
are paid in full when due and as planned with no premium holiday and the current scale of charges remains unchanged. Any deviation
from this will change the illustrated values accordingly.
8. A loyalty bonus, credited on the 15th and 25th policy years, is included in the illustration. The bonus is estimated to be 5% of the
average of the month-end Account Values over the last 120 months.
9. 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.

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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.

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DECLARATIONS AND ACKNOWLEDGMENTS

DECLARATIONS
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:
_____________________________ ____________________ _____________________________________ ________________________

Applicant/Policy Owner Date Financial Advisor/Financial Executive Date
Signature over Printed Name Signature over Printed Name
TO BE FILLED UP BY AXA PHILIPPINES

_________________________ _________________________
These declarations and acknowledgments are valid for _________________________ _________________________
the following policy/ies with policy number/s: _________________________ _________________________
Disclosure of Conflict of Interest
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.

Reference no.: 39803-201907120719-2-
02
INVESTMENT PORTFOLIO RISK ASSESSMENT
You prefer a growth investment portfolio
Growth Investment Portfolio : A growth investment portfolio is characterized by a willingness to accept higher than
average level of risks and price volatility in pursuit of above average returns.
- 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.
INVESTMENT PORTFOLIO RISK ACKNOWLEDGMENT
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.
INVESTMENT POLICY STATEMENT
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:
Applicant/Policy Owner Date

Signature over Printed Name
Reference Number: 39803-201907120719-2-02
FINANCIAL UNDERSTANDING SUMMARY
Dear KID ERNEST JONES
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.
DOMIDER, DERWIN BAUTISTA

212020
39803
639177134545
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
Client's Declaration Form

I have actually read and understood the full text of the Declarations, Agreements and Acknowledgment
of the Forms before signing them:
Application Form: 39803-201907120719-2-02

Proposal/Illustration of Benefits: 39803-201907120719-2-02
Investment Portfolio Risk Assessment Form 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.
KID ERNEST JONES REBUYON

Name and Signature Of Policy Insured
Signed On:
Place of Signing:

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Policy Number

Application Number R 39803-201907120719-2-02

Traditional Variable Multiple Application

1. DETAILS OF PROPOSED INSURED

KID ERNEST JONES Please accomplish as

DATE OF BIRTH(YYYY/MM/DD) PLACE OF BIRTH Politically Exposed Person (PEP)

PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business

Maturing Investment/Php Others: 15000.00

IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX RESIDENT? No Yes US TIN/SSN:

2. DETAILS OF PROPOSED OWNER (If different from Proposed Insured)

FIRST NAME Accomplish only if

(If yes, please specify government position/public office)

IF WORKING ABROAD, STATE THE CITY PROVINCE AND COUNTRY

Residence Address should be

PREFERRED MAILING ADDRESS (Select One) Residence Permanent Address Business

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

BENEFICIAL OWNER (If any)

NATURE OF BUSINESS FULL NAME OF AUTHORIZED SIGNATORY

*Authorized signatory/ies will be asked to provide required additional information

CONTACT INFORMATION OF AUTHORIZED SIGNATORY

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

4. BENEFICIARY DESIGNATION Notes

Secure (AD&D) Critical Illness Protector (Term)

YRT 20YRT UP TO AGE 55 YRT 20YRT UP TO AGE 55 YRT 5YRT 10YRT

5 PAY 10 PAY 20YRT UP TO AGE 55

5 PAY 10 PAY 5 PAY 10 PAY

20 PAY 20 PAY UP TO AGE 55

Others Rider Name Rider Sum Insured

Rider Name Rider Sum Insured Applicable only for term

7. CONVERSION OF TERM INSURANCE

Credit card payment is

All fund allocations

10. DETAILS FOR VARIABLE INSURANCE

Lump Sum Top-up Amount

FUND NAME % ALLOCATION FUND NAME % ALLOCATION

1. Philippine Wealth Equity Fund 30 4.

3. Chinese Tycoon Fund 60 6.

Proposed Insured Proposed Owner If "Yes", please

5. Do you participate or intend to participate in any hazardous activities

1. Height 5'4"(ft. & in.) or 162(cm.) and weight 149lbs. or 67.5853kg.

b. Cancer (including melanoma), tumor or growth of any kind. Yes No Yes No

c. Diabetes, thyroid disease, metabolic or endocrine diseases. Yes No Yes No

d. Hepatitis B or C (including Hepatitis carrier), HIV infection, liver, Yes No Yes No

f. Any musculoskeletal diseases (including joint/bone diseases, arthritis) Yes No Yes No

g. Eyes/ears/nose/throat diseases, or any respiratory diseases. Yes No Yes No

h. Epilepsy, head/brain injury, paralysis, psychiatric diseases or other Yes No Yes No

4. Are you currently receiving any medical treatment or intend seeking or

5. Have your biological mother, father, brother(s) or sister(s) been

12. REPLACEMENT OF EXISTING LIFE INSURANCE POLICIES

13. DECLARATIONS AND AGREEMENT:

on the policy that will be issued;

14. TELEPHONE UNDERWRITING AUTHORIZATION

During office hours (8 am-5 pm) Others, please specify

15. REQUEST FOR DIRECT CREDIT TO BANK ACCOUNT

Policy No.: Account type: Bank Name:

Peso account Dollar account Metrobank Others:

Branch Name: Swift Code (for Non-Metrobank) Account Number of payee:

Account Name of payee: Relationship to owner

Spouse Child Parent Sibling

**PLEASE DO NOT SIGN ON A BLANK FORM

Date of Signing: Place of Signing:

KID ERNEST JONES REBUYON

Name of Advisor/FE: DOMIDER, DERWIN BAUTISTA Name of Advisor/FE:

___________ _ ______