Policy Number

Application Number R 24788-201708220802-3-02

Traditional Variable

Application for Life Insurance

Accomplish the details and put “N/A” if not applicable. Print legibly using BLACK FOR OFFICE USE ONLY
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. Date Received:
Time Received:
Important Notes: Receiving
Dept./Office:
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 insurer.
All answers to the questions stipulated in this questionnaire are the basis of and
are an inseparable part of the insurance policy. In case of doubt as to whether a
fact is material or not, the fact
should be disclosed.
2. Please do not sign on a blank form.
3. Please shade the circle to indicate your choice(s).

LAST NAME Notes

BROWN

FIRST NAME Please accomplish as

well the “Proposed
MA DAISY Owner Details” section
at the back page if the
MIDDLE NAME Proposed Owner is
different from the
SAPETIN Proposed Insured.

DATE OF BIRTH ( YYYY/MM/DD) PLACE OF BIRTH SEX WEIGHT (lbs.) (kg.) HEIGHT (ft. & in.) (cm)

1978/12/03 SAMAR Male Female 50.00 157.00

NATIONALITY OCCUPATION IDENTITY NO. (TIN/SSS/GSIS)

Philippines House Wife, House Husband Drivers License: N04-09-017767

RESIDENCE ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE
Residence Address
should be a Philippine
Address (in reference to
Cross-Border Rule)
PHASE 3 BLOCK 83 LOT 1 EASTWOOD RESIDENCES SUBD BRGY. SAN ISIDRO RODRIGUEZ RIZAL 1860
Residence Address
shall be used as default
BUSINESS ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE mailing address

Unless you are a bank

PHASE 3 BLOCK 83 LOT 1 EASTWOOD RESIDENCES SUBD BRGY. SAN ISIDRO RODRIGUEZ RIZAL 1860 employee, Bank
address and contact
information should not
be used
PREFERRED MAILING ADDRESS (Select One) Residence Business

CONTACT NUMBERS (Pls. provide at least two)

HOME PHONE NUMBER MOBILE NUMBER (Mandatory)

0024232392 639328900645

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)

0 DAISYBROWNRD@YAHOO.COM

SOURCE OF FUNDS Answer this question

Salaries Income from business Savings Others only if Proposed Insured
remittance
is the same as the
Proposed Owner
IS THE PROPOSED INSURED/OWNER A US CITIZEN OR US TAX Yes No
RESIDENT?
Application For Life Insurance Application Number R 24788-201708220802-3-02

LAST NAME Notes

FIRST NAME Accomplish only if

Proposed Owner is
different from Proposed
Insured
MIDDLE NAME

DATE OF BIRTH ( YYYY/MM/DD) PLACE OF BIRTH SEX WEIGHT (lbs.) (kg.) HEIGHT (ft. & in.) (cm)

Male Female Residence Address

should
be a Philippine Address
NATIONALITY OCCUPATION IDENTITY NO. (TIN/SSS/GSIS) (in reference to
Cross-Border Rule)

Residence Address
RESIDENCE ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE shall
be used as default
mailing
address

BUSINESS ADDRESS (PLS. INCLUDE NO., STREET, CITY, PROVINCE ) ZIP CODE

The Contingent Owner

PREFERRED MAILING ADDRESS (Select One) Residence Business will automatically
become the new Owner
of the policy in the
CONTACT NUMBERS (Pls. provide at least two)
event that the Owner
HOME PHONE NUMBER MOBILE NUMBER (Mandatory) predeceaces the
Insured while this Policy
is in force.

If the owner has not

BUSINESS PHONE NUMBER E-MAIL ADDRESS (Mandatory)
appointed a Contingent
Owner, the Insured
shall automatically
become the new Owner
of this Policy in the
RELATIONSHIP OF PROPOSED CONTINGENT OWNER UPON DEATH RELATIONSHIP OF CONTINGENT event that the Owner
OWNER TO THE PROPOSED OF OWNER OWNER predeceases the
INSURED TO PROPOSED INSURED Insured while the policy
is in force.

Designation of a minor
SOURCE OF FUNDS as Contingent Owner is
Salaries Income from Savings Others discouraged.
business

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

Benefits shall be
equally divided among
all persons in the same
category.

"Children" shall include

legitimate &
*Unless otherwise indicated, Beneficiaries shall be deemed primary revocable. If the Beneficiary is not changed illegitimate.
during the lifetime of the insured, the designation shall be deemed irrevocable.
If you designate irrevocable Beneficiaries, you will need the consent of all such Beneficiaries for any and all after- If you take the standard
sales transaction. To designate irrevocable Beneficiaries from among those listed below, write down the names of the option, there is no need
irrevocable Beneficiaries on the space on Page 4, No. 12 Home Office Endorsement and Special Instructions. to indicate the name.

Standard 1. Spouse 2. 3. Parents 4. Siblings 5. Estate

Children Surviving Beneficiaries
in the same
classification will
TYPE OF equally share in the
By Name DATE OF RELATIONSHIP TO BENEFIT BENEFICIARY benefits.
BIRTH PROPOSED INSURED %
PRIMARY SECONDARY
Designation of a minor
BROWN, RAYMOND M 10/5/1967 Spouse 10 as Irrevocable
beneficiary is
discouraged.
BROWN, DESIRAE FAYE SAPETIN 12/7/2010 Child 45
Secondary Beneficiaries
are entitled to the
BROWN, ISAIAH DESMOND SAPETIN 9/8/2013 Child 45
benefits if no Primary
Beneficiary survives.
Application For Life Insurance Application Number R 24788-201708220802-3-02

PREMIUM TYPE CURRENCY SUM INSURED SINGLE PREMIUM

Notes
Regular Pay Single Pay Peso Dollar
150,000.00
Single Premium refers
PLAN NAME PAYMENT TERM, If applicable YEARS TO MATURE, If applicable to a single one-off
payment that covers
Axelerator the entire cost of
the Policy.

Secure (AD&D) Shield (CI) Protector (Term)

SUM INSURED SUM INSURED 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

Selection of “Waiver of
5 Pay 10 Pay
5 Pay Premium” or “Payor’s
10 Pay 20 Pay Clause” as policy
UP TO AGE 55
supplement applies
20 Pay to the basic and
supplement riders
where it is applicable
Care (Hospital Income) YRT 20YRT UP TO AGE 55
Waiver of Premium

Economy Superior
Economy Superior Premier
Payor's Clause Regular Premier

Others Rider Name Rider Sum Insured

Rider Name Rider Sum Insured

Applicable only for term

products with conversion
provisions. Conversion
Policy No*./Certificate No**. * For Individual, Basic Term or Term rider plans
is subject to our internal
guidelines
** For Group Term plans

Payor should be
Policy Owner, Insured
MODE OF PAYMENT METHOD OF PAYMENT
or immediate family
Annual Semi-annual Auto-Debit Arrangement (ADA) Credit Card
member of P.O.

Quarterly Monthly Post Dated Check (PDC) Cash Others

: Billing cycles for policies
enrolled under ADA and
Credit Card payment
shall be subject to the
collection schedule
set by the Company.

* DIVIDEND/ENDOWMENTS
** PREMIUM OPTION
OPTIONS
Accumulate with Interest Extended Term Insurance (ETI)

Apply to premiums Reduced Paid Up (RPU)

Pay in cash Automatic Premium Loan (APL)

* By default, if no Dividend/Endowment Options is ** By default, if no Premium Option is selected, below will

selected, below will apply: Accumulate with Interest apply: ETI – for standard cases; RPU – for substandard
cases

TOP-UP OPTIONS, If applicable DEATH BENEFIT OPTIONS, If applicable

Regular Annual Top-Up Level Increasing Fund allocation for

Lump Sum Top-up Amount
3GX products shall be
determined by AXA.
Fund Name % ALLOCATION Fund Name % ALLOCATION
1. Chinese Tycoon Fund 100 5. All fund allocations
should total to 100%
2. 6.

3. 7.

4. 8.
Application For Life Insurance Application Number R 24788-201708220802-3-02

Proposed Insured Proposed Owner If “Yes”, please

(Owner to answer if payor’s indicate details
clause is applied for)
1. Do you smoke cigarettes/cigars? (If yes, indicate no. of sticks/day Yes No Yes No PI O
& no. of years)
no. of sticks/day
months/years

2. In the last 2 years, have you: Yes No Yes No

a. Consulted a medical doctor or been referred for tests or
investigation or had any medical test/s

b. Been diagnosed, or received treatment, medication or Yes No Yes No

advice pertaining to unexplained weightloss, high
blood, heart or lung disease, diabetes, tumor or cancer,
mental or neurologic dysfunction, liver disease, or any
other ailment with or without physical impairment?

3. Have you had at least 2 immediate family members (parent or Yes No Yes No
siblings) who were diagnosed or died of hypertension, diabetes,
heart or kidney disease, mental illness or cancer or any diseases
not mentioned above prior to age 50?

4. Including this new application, is your total insurance cover above Yes No Yes No
Php3m?
If yes, please provide the company name, product type and /or
riders, amount of coverage and issue date?

5. In the last 2 years, have you participated in sky/scuba diving, Yes No Yes No
bungee jumping, motor racing or hazardous sports or activities for
more than 3x?

6. Do you currently hold or intend to be a candidate in a public Yes No Yes No Position:

elective office?
Location:

7. For Female Applicant Only Yes No Yes No If yes, how many months?
Are you currently pregnant? Any complications?

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

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.
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.
Application For Life Insurance Application Number R 24788-201708220802-3-02

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 policy, whether the minor is a revocable or
irrevocable beneficiary, a court appointed guardian and guardian's bond will be required.
5. I/We understand that choosing standard beneficiary will mean that my policy benefits will be payable to the person or persons
then surviving in the following order of preference unless changed by me/us in writing; (1) My surviving spouse; (2) My surviving
children; (3) My surviving parents; (4) My surviving brothers and sisters; (5) My estate executor or administrator.
6. All the information I provided on this application from are to the best of my knowledge true and correct.
7. Any of my 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 any of its affiliated companies, or any individuals/organizations associated with AXA Philippines:
a. to process and deal with the application
b. to provide all services related to the application and promote the services by AXA Philippines and its affiliated companies
c. to communicate with me for any purpose and/or comply with the laws of any applicable jurisdiction.
8. I have the right to request access to and correct any of my personal information held by AXA Philippines. I understand that such
request may be made in writing and submitted to the Policy Services Unit of AXA Philippines
9. I/We understand that AXA 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 to disclose to affiliated entity(ies) or to persons or entities providing services on AXA’s behalf consistent
with the purpose for which the information was obtained
10. I understand that notices related to my policy may be sent to me through email or SMS in the address/number I provided above.
11. I/We declare that I/we have informed AXA of all my/our citizenships, residencies and tax residencies, and provided AXA with
my/our taxpayer identification number(s). I/We agree to promptly update AXA of any changes to said information. I/We authorize
AXA 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 shall have the right to: (a)
require the claimant(s) and/or payee(s) of the Policy to provide AXA with their above-mentioned personal information and/or sign
such documents as AXA 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 may provide my/our personal information to such government or taxation
authority(ies) to comply with the applicable laws and regulations.
12. 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.
13. 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.
14. 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.

15. In case of apparent errors or omissions in this Application, or if the Corporation is unwilling to issue the policy applied for, AXA
Philippines may amend this Application by noting the change in the space entitled “Home Office Endorsement” and issue the
policy on the basis of such amended Application, and acceptance of such policy by the Applicant will ratify such amendment.
16. 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.
17. I/We have read and fully understood the Life Insurance Proposal (or the illustration of benefits) for the policy applied for.

18 An electronic copy of this application (i.e. scanned or faxed) shall be binding to me/us and shall be considered as good as the
original manually signed document. I/We will inform the Company of any discrepancy between the electronic copy and the
original as soon as possible, and I/we understand that absent any correction within a reasonable period, the Company is entitled
to rely on the electronic copy exclusively.

19. 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 the Corporation before it is approved, I/we can refund all
the premium deposits paid by me/us and received by the Corporation. If such notice is received by the New Business and
Underwriting Department of the Corporation 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.
Application For Life Insurance Application Number R 24788-201708220802-3-02

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

Policy No.: Account Type: Bank Name:

Peso Account Dollar Metrobank Others
Account

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:

MA DAISY BROWN
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: OLIVEROS, JESSICA FERRERIA Name of Advisor/FE:

Code: Code:

600103 4 24788

Signature: Signature:
Application For Life Insurance Application Number R 24788-201708220802-3-02

Please refer to the back page for the Declaration and Reminders of this application form

CREDIT CARD ENROLLMENT FORM

Account Type: Visa Mastercard Month Year

Credit Card Expiry Date /

Number

Credit Card Company: Billing Address:

Cardholder's Name:

(Last Name) (First Name) (Middle Name)

Cardholder's Birthday: Amount of Premium:

Mother's Maiden Name: Name of Insured:

Contact Number(s)
of Cardholder: Policy Number:

Relationship of cardholder to Owner of policy

Visa Spouse Sibling (To be signed by the Policy Owner if different from Cardholder)

Signature over printed name of Cardholder Signature over printed name of Policy Owner

24788-201708220802-3-02
Application Number R
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. 9 were answered “NO” by the Proposed Insured 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 amount of insurance money payable 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. In no event however, will AXA Philippines pay 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, including any accidental death benefit,
under all Temporary Life Insurance Certificates inforce in respect of the Proposed Insured. However, if the amount of insurance 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.

EXCLUSION: 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.
Application For Life Insurance Application Number R 24788-201708220802-3-02

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 may also cancel this payment arrangement upon prior written notice duly
received and accepted by AXA Philippines.
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.

Reminders

1. 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.
2. Billing cycle: policies with 1-15 as Effective Date shall be initially charged on the 5th of every month
while those 16-28 as Effective Date shall be initially charged every 20th of the month. For rejected
billings due to insufficient balance, we will initiate rebilling efforts in an objective to keep your policy
inforce.
3. No premium notice shall be issued to policies paid under Auto-charge credit card.

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 pubassist@insurance.gov.ph.
The official website of the Insurance Commission is www.insurance.gov.ph.
 Proposed Insured:
MA DAISY SAPETIN BROWN
Age 39, Female, Non-smoker

Policyowner or Payor:
MA DAISY SAPETIN BROWN
Age 39, Female

Dear MA DAISY,

Thank you for your interest in AXA products. Axelerator is a regular-pay variable life insurance product that provides greater opportunity
for investment growth to help you meet your financial goals sooner while providing basic life protection for you and your loved ones. 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 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 30,000.00 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% annual rate (PHP)
4% annual rate of return, Account Value 1,225,395 Age 50 434,330
Or 8% annual rate of return, Account Value 2,239,690 Age 60 1,406,088
Age 70 3,464,524
Or 10%annual rate of return, Account Value 3,073,545

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%, 8%, and 10%. 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 9 of 17 of Proposal No. 24788-201708220802-3-02

Printed on: 8/22/2017 8:11:52 PM Created on: 8/22/2017 8:01:43 PM Expiry Date: 11/22/2017
Version Number: 3.9.5 Date for Next Insurance Age: 6/3/2018
Plan Code: AXE
 Philippine Peso
for: MA DAISY SAPETIN BROWN, 39

SPECIAL FEATURES

Top-ups 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 10th and 20th
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.

The succeeding pages of this proposal provide more details on the benefits and features of Axelerator.

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.

OLIVEROS, JESSICA FERRERIA

600103
24788

Page 10 of 17 of Proposal N 24788-201708220802-3-02

Printed on: 8/22/2017 at 08:11 PM Created on: 8/22/2017 8:01:43 PM Expiry Date: 11/22/2017
Version Number: 3.9.5 Date for Next Insurance Age: 6/3/2018
Plan Code: AXE
 Philippine Peso
for: MA DAISY SAPETIN BROWN, 39

Axelerator 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 minimum Death Benefit in this proposal is PHP
150,000 1 .
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
Axelerator 100 150,000 30,000.00
Total² 30,000.00

You may also pay your premium in the following modes:

Modes of Payment Modal Premium Fund Name ³ Fund Allocation
(PHP)
Semi-Annual 15,000.00 Chinese Tycoon Fund 100%
Quarterly 7,500.00
Monthly 2,500.02

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 Axelerator 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.

Page 11 of 17 of Proposal N 24788-201708220802-3-02

Printed on: 8/22/2017 at 08:11 PM Created on: 8/22/2017 8:01:43 PM Expiry Date: 11/22/2017
Version Number: 3.9.5 Date for Next Insurance Age: 6/3/2018
Plan Code: AXE
 Philippine Peso
for: MA DAISY SAPETIN BROWN, 39

ILLUSTRATION OF BENEFITS

The illustrated benefits of your policy (subject to actual market performance) are shown below.

Total Cumulative ILLUSTRATION OF BENEFITS

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 30,000 17,802 150,000 18,514 150,000 18,870 150,000
2 60,000 36,353 150,000 38,549 150,000 39,669 150,000
3 90,000 55,672 150,000 60,218 150,000 62,582 150,000
4 120,000 86,221 150,000 94,488 150,000 98,858 150,000
5 150,000 118,066 150,000 131,588 150,000 138,859 150,000
10 300,000 304,659 304,659 374,744 374,744 416,067 416,067
15 450,000 524,967 524,967 724,307 724,307 854,237 854,237
20 600,000 819,107 819,107 1,274,521 1,274,521 1,603,562 1,603,562
25 750,000 1,150,871 1,150,871 2,046,374 2,046,374 2,766,709 2,766,709
30 900,000 1,554,513 1,554,513 3,180,480 3,180,480 4,639,971 4,639,971
35 1,050,000 2,045,606 2,045,606 4,846,853 4,846,853 7,656,877 7,656,877
40 1,200,000 2,643,095 2,643,095 7,295,303 7,295,303 12,515,634 12,515,634
45 1,350,000 3,370,032 3,370,032 10,892,879 10,892,879 20,340,710 20,340,710
50 1,500,000 4,254,461 4,254,461 16,178,898 16,178,898 32,943,075 32,943,075
55 1,650,000 5,330,505 5,330,505 23,945,794 23,945,794 53,239,309 53,239,309
60 1,800,000 6,639,677 6,639,677 35,357,912 35,357,912 85,926,597 85,926,597

Age65 780,000 1,225,395 1,225,395 2,239,690 2,239,690 3,073,545 3,073,545

Age70 930,000 1,645,182 1,645,182 3,464,524 3,464,524 5,134,132 5,134,132
Age75 1,080,000 2,155,919 2,155,919 5,264,208 5,264,208 8,452,729 8,452,729
Age80 1,230,000 2,777,307 2,777,307 7,908,533 7,908,533 13,797,361 13,797,361
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% of the basic premium for the 1st to 3rd 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.

Page 12 of 17 of Proposal N 24788-201708220802-3-02

Printed on: 8/22/2017 at 08:11 PM Created on: 8/22/2017 8:01:43 PM Expiry Date: 11/22/2017
Version Number: 3.9.5 Date for Next Insurance Age: 6/3/2018
Plan Code: AXE
 Philippine Peso
for: MA DAISY SAPETIN BROWN, 39

ILLUSTRATION OF BENEFITS (with Premium Holiday on Year 5)

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 5 and/or withdrawals from the fund assuming different
rates of return. However, note that the rates of return are for illustration purposes only. They are not based on past performance nor
guarantee future returns.

The illustrated benefits of your policy (subject to actual market performance) are shown below.

Total Cumulative ILLUSTRATION OF BENEFITS (with Premium Holiday on Year 5)

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-
up, if any, Paid Living Benefit Death Benefit Living Benefit Death Benefit Living Benefit Death Benefit
1 30,000 17,802 150,000 18,514 150,000 18,870 150,000
2 60,000 36,353 150,000 38,549 150,000 39,669 150,000
3 90,000 55,672 150,000 60,218 150,000 62,582 150,000
4 120,000 86,221 150,000 94,488 150,000 98,858 150,000
5 150,000 118,066 150,000 131,588 150,000 138,859 150,000
10 150,000 141,080 150,000 191,268 191,268 221,708 221,708
15 150,000 164,955 164,955 273,694 273,694 349,345 349,345
20 150,000 201,960 201,960 408,183 408,183 572,222 572,222
25 150,000 239,076 239,076 592,414 592,414 913,853 913,853
30 150,000 284,233 284,233 863,108 863,108 1,464,052 1,464,052
35 150,000 339,173 339,173 1,260,848 1,260,848 2,350,153 2,350,153
40 150,000 406,017 406,017 1,845,258 1,845,258 3,777,227 3,777,227
45 150,000 487,342 487,342 2,703,948 2,703,948 6,075,545 6,075,545
50 150,000 586,286 586,286 3,965,645 3,965,645 9,777,009 9,777,009
55 150,000 706,667 706,667 5,819,493 5,819,493 15,738,253 15,738,253
60 150,000 853,129 853,129 8,543,402 8,543,402 25,338,897 25,338,897

Age65 150,000 247,413 247,413 638,555 638,555 1,003,974 1,003,974

Age70 150,000 294,377 294,377 930,906 930,906 1,609,193 1,609,193
Age75 150,000 351,514 351,514 1,360,464 1,360,464 2,583,904 2,583,904
Age80 150,000 421,032 421,032 1,991,627 1,991,627 4,153,686 4,153,686
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% of the basic premium for the 1st to 3rd 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
5 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 1st to 10th policy years on the 10th year, and 5% of the average Account
Value from the 11th to 20th policy years on the 20th year is included in the 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.

Page 13 of 17 of Proposal N 24788-201708220802-3-02

Printed on: 8/22/2017 at 08:11 PM Created on: 8/22/2017 8:01:43 PM Expiry Date: 11/22/2017
Version Number: 3.9.5 Date for Next Insurance Age: 6/3/2018
Plan Code: AXE
 Philippine Peso
for: MA DAISY SAPETIN BROWN, 39

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 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%, 8.00%, and 10.00%. These rates are for illustration purposes only and do not represent maximum or
minimum return on your fund value.
5. A bid-offer spread, which is the difference between the bid price and the offer price of units, may be determined by AXA Philippines from time to
time. The above illustration is based on a bid-offer spread of 5%.
6. This illustration summary relates to your Axelerator 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.
7. A loyalty bonus, credited on the 10th and 20th 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.
8. 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. Axelerator 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.
The death benefit will be the higher of the Sum Insured less the partial withdrawals made for the past twelve (12) months, and the Account
Value.
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 canceling 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.

Page 14 of 17 of Proposal N 24788-201708220802-3-02

Printed on: 8/22/2017 at 08:11 PM Created on: 8/22/2017 8:01:43 PM Expiry Date: 11/22/2017
Version Number: 3.9.5 Date for Next Insurance Age: 6/3/2018
Plan Code: AXE
 Philippine Peso
for: MA DAISY SAPETIN BROWN, 39

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 Axelerator premium, regular
top-up premium, and Supplement premiums shown above, if any. I was also made aware that only the Axelerator 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.

Page 15 of 17 of Proposal N 24788-201708220802-3-02

Printed on: 8/22/2017 at 08:11 PM Created on: 8/22/2017 8:01:43 PM Expiry Date: 11/22/2017
Version Number: 3.9.5 Date for Next Insurance Age: 6/3/2018
Plan Code: AXE
 Reference Number: 24788-201708220802-3-02

FINANCIAL UNDERSTANDING SUMMARY

Dear MA DAISY

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 50,000.00, and after taking into consideration your objectives, risk
profile and priorities, you have selected Axelerator for your Retirement need.

The details of your insurance coverage and your insurance premium are summarized in your
Axelerator sales illustration.

OLIVEROS, JESSICA FERRERIA

600103
24788

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: 24788-201708220802-3-02

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: 24788-201708220802-3-02

Proposal/Illustration of Benefits: 24788-201708220802-3-02
Investment Portfolio Risk Assessment Form 24788-201708220802-3-02

I also understand that this Client’s Declaration Form shall form part of the insurance contract once the
Policy is issued.

MA DAISY BROWN
Name and Signature Of Policy Insured

Signed On:

Place of Signing: