Application form. Global Term

Transcription

1 Application form Global Term

2 General Information If you have already applied for cover with us, please state your policy number, if known. Part 1: Financial adviser details to be completed by the adviser Company name Company address Agency number Contact details for acknowledgement/queries on the application. Adviser name Telephone number Fax number address Where the application is for cover(s) other than Life Cover, I have passed the relevant health insurance module conducted by the Singapore College of Insurance. 1 I have submitted the equivalent of sections 11, 12 and 13 of the Life Insurance Advisory Form (Life Insurance Association, Singapore). 2 Choose either of the following: a) The client(s) and I have completed the needs analysis according to the Life Insurance Association s Life Insurance Advisory Form. b) The client(s) have opted not to carry out the needs analysis according to the Life Insurance Association s Life Insurance Advisory Form. Country where advice is given Country where application is signed Signature (to be signed by the adviser) 3 Client(s) must endorse if option 2(b) above has been selected: I/We have opted not to carry out the complete needs analysis according to the Life Insurance Association s Life Insurance Advisory Form with my/our Adviser. If a material fact is not disclosed in this application, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to the financial adviser but was not included in the application. Please check to ensure that you are fully satisfied with the information declared in this application. First (or only) life assured/applicant /applicant Signature(s) Date (DD/MM/YYYY) Failure to provide all relevant information and documentation will result in a delay to the application being processed. Further information may be required during the validation process (i.e. questions arising from the information provided). Please note that even if the premium has been received and banked, the policy will not be issued until all documentation has been received and validated. Please complete this form in black ink. If you make any mistakes while completing this application form, please cross out the error and write the new information clearly. The life assured must initial any corrections for questions they have answered. Do not use correction fluid or other ways of deleting incorrect information. Checklist please complete all sections Parts 2 10 Fully completed Pages Payment details Part 12 Personal Data Protection Act 2012 (PDPA) Personal Data Protection Consent Declaration Part 13 Declarations signed Enclosed certified copies of client s identity Enclosed certified copies of client s utility bill (or suitable alternative) to verify residential address 2 Friends Provident International Global Term Application form

3 WARNING: PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT OF SINGAPORE (CAP.142), YOU ARE TO DISCLOSE IN THIS APPLICATION FORM, FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE THE POLICY ISSUED HEREUNDER, MAY BE VOID. It is most important that you read this part before completing the application form. This application form should be read in conjunction with the following documents, which set out the terms and conditions of the contract: the Global Term product summary Your Guide to Life Insurance Your Guide to Health Insurance the Global Term policy conditions Infographic: Evaluating my health insurance coverage Your personal benefit illustration. (To be read together with Your Guide to Health Insurance) Declaration Please tick all appropriate boxes and sign where indicated before proceeding. Accredited and Non-Accredited Investors The applicant(s) must state whether or not they are an Accredited Investor as defined under Section 4A of the Securities and Futures Act (Cap.289) ( SFA ). Under this Act, an Accredited investor means an individual: a) whose net personal assets exceed in value SGD 2 million (or its equivalent in a foreign currency) or such other amount as the Authority may prescribe in place of the first amount; or b) whose income in the preceding 12 months is not less than SGD 300,000 (or its equivalent in a foreign currency) or such other amount as the Authority may prescribe in place of the first amount. There are also requirements for corporate investors. Please refer to the SFA for more details. This definition may be changed by the Monetary Authority of Singapore from time to time. First (or only) applicant Second applicant Accredited Investor Non-Accredited Investor If a material fact is not disclosed in this application, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to the financial adviser but was not included in the application. Please check to ensure that you are fully satisfied with the information declared in this application. Signature(s) Date (DD/MM/YYYY) Part 1: Replacement of life policies First (or only) life assured a) Does the policyholder have any existing life insurance policy(ies) with Friends Provident International or any other financial institutions? If Yes, please complete the following table. First (or only) life assured Name of company Country of insurance Type of policy Sum assured Year issued Currency Term 3

4 Part 1: Replacement of life policies (continued) Name of company Country of insurance Type of policy Sum assured Year issued Currency Term b) Is this application intended to replace any policies of any other financial institutions including Friends Provident International? First (or only) life assured If Yes, please indicate the policy numbers below. Relevant information Warning: It is usually disadvantageous to replace an existing life insurance policy with a new one. Some of the disadvantages are: i) You may not be insurable on standard terms. ii) You may have to pay a higher premium in view of a higher age. iii) This may result in losing the financial benefits accumulated over the years. In your own interest, we would advise that you consult your present insurer before making a financial decision. You can then make a careful comparison. 1 Disclosure of all relevant information Help us to assess your application by giving us all the information we ask for. All the questions we ask are relevant and important. You must answer them accurately and completely to the best of your knowledge. If you do not, we will have the legal right to cancel any policy issued as a result of your application and to not pay any claim. If anything about your health or circumstances changes after you have completed this application and before we assume risk for the cover applied for, you must let us know immediately. We need to know of any changes which would have resulted in different replies to questions asked either: on or resulting from the application form or other questionnaire; or by any doctor or nurse acting on our behalf. To inform us of any such change, please telephone our Singapore office on +(00) ; singapore.enquiries@fpiom.com Changes would include having, or expecting to have, doctor, hospital or clinic consultations, treatment as an in-patient or out-patient or a blood test for any reason. We also need to know immediately if you change your occupation, country of residence or intended residence, or take up any hazardous sports or pastimes before cover starts. If we are advised of any changes, we will confirm in writing whether or not any terms quoted will still apply. 2 Terms and conditions You should seek guidance from your usual financial adviser as to the suitability of the policy to your own particular circumstances. Before completing this application, you should read our standard terms and conditions. You are entitled to ask for a copy of your application form at any time. 3 Medical evidence Friends Provident International will only pay for medical information which it has specifically requested. 4 Friends Provident International Global Term Application form

5 Please write in black ink and use BLOCK CAPITALS. Policy details Part 2: Lives assured details The life (lives) assured is/are the person(s) on whose life (lives) the policy will be written. First (or only) life assured 1 Title Mr Mrs Miss Ms Mr Mrs Miss Ms Other Other 2 Surname (as shown on NRIC or passport) 3 First name(s) (as shown on NRIC or passport) 4 Aliases If Yes, please specify 5 Unique identification number (NRIC or passport) 6 Permanent residency visa number (if applicable) or ID number (if applicable) 7 Marital status Single Married Widowed Single Married Widowed 8 Date of birth (DD/MM/YYYY) 9 Current residential address (including street name, town and area code, if known) Divorced Other Divorced Other 10 How long have you lived at this address? 11 Correspondence address (if different to residential address) 12 Relationship or nature of interest between the two lives assured (if applicable) You will receive your policy documents and all correspondence relating to your plan, unless you indicate otherwise below. Copies will also be sent to your financial adviser. Alternatively, please tick here if you would prefer us to send your policy documents and all correspondence relating to your policy to your financial adviser only. I/We acknowledge that the above indication of preference does not prohibit direct responses to enquiries from yourselves or my/our financial adviser. 13 Please list all contact details below. Contact details Home telephone number (mandatory) Office telephone number (mandatory) Mobile number (mandatory) address (mandatory) 5

6 Part 2: Lives assured details (continued) Medical details 14 Do you have a regular doctor or medical practitioner? Please note that we might not contact your doctor. Even if we do, you must still disclose all facts when completing this application. If Yes, provide full name and address of your regular doctor or medical practice/centre, including fax number. Doctor s or medical practitioner s full name Doctor s or medical practitioner s address Medical practice/centre name Medical practice/centre fax number How long has your regular doctor known you? Years Months Years Months When did you last attend your regular doctor? (DD/MM/YYYY) What was the reason for your last visit? Part 3: Occupation First (or only) life assured 1 What is your occupation? (If you have more than one occupation, please provide full details of each one.) 2 What is the name of your employer? 3 What is the address of your employer? 4 What is the nature of your employer s business? (e.g. Financial Services) 5 Please give details if you work underground, underwater, at heights over 3 metres, offshore or any other hazardous aspects of your occupation. 6 Please give percentage of working time spent at heights, if applicable. 7 Please give average and maximum heights worked (in metres). % % Average Maximum Average Maximum 6 Friends Provident International Global Term Application form

7 Part 4: Plan details Please indicate required currency: SGD USD HKD GBP EUR Please indicate premium payable: Monthly Annually The minimum amount of cover for any individual policy is SGD 845,000, USD 500,000, HKD 4,000,000, GBP 282,000, EUR 437, How much Life Cover do you require? A policy for first life assured only A policy for second life assured only A policy for joint lives assured Amount of cover Amount of cover Amount of cover or or or Amount of premium Amount of premium Amount of premium Term years Term years Term years Total and Permanent Disability Benefit Tick box if you are placing your policy under trust prior to policy production Total and Permanent Disability Benefit Tick box if you are placing your policy under trust prior to policy production Total and Permanent Disability Benefit First life assured Both lives Tick box if you are placing your policy under trust prior to policy production (Guaranteed premiums. Maximum to age 80. However, Total and Permanent Disability Benefit, if selected, will cease on the life assured s 65th birthday.) 2 How much Life or Earlier Critical Illness Cover do you require? A policy for first life assured only A policy for second life assured only A policy for joint lives assured Amount of cover Amount of cover Amount of cover or or or Amount of premium Amount of premium Amount of premium Term years Term years Term years Tick box if you are placing your policy under trust prior to policy production (Reviewable premiums, maximum to age 80.) Tick box if you are placing your policy under trust prior to policy production Tick box if you are placing your policy under trust prior to policy production 7

8 Part 4: Plan details (continued) 3 How much Critical Illness Cover do you require? A policy for first life assured only A policy for second life assured only A policy for joint lives assured Amount of cover Amount of cover Amount of cover Amount of premium or or or Amount of Amount of premium premium Term years Term years Term years Tick box if you are placing your policy under trust prior to policy production Tick box if you are placing your policy under trust prior to policy production Tick box if you are placing your policy under trust prior to policy production (Reviewable premiums, maximum to age 80.) Start date Should anything about your health or other circumstances change before Friends Provident International has assumed risk for the policy you have applied for, you must tell us immediately. We will then confirm whether any terms we have quoted will remain available. Failure to notify us of any such change may result in the policy becoming void and the benefits not becoming payable. We will start your policy immediately if your application is accepted on our normal terms, unless you state a date below on which you would like it to start or have instructed us otherwise. If your application is not accepted on our normal terms, the policy will not start until we receive written notification of your acceptance of any revised terms Friends Provident International offers, and your instructions to go on risk. In any event, risk cannot be assumed under the Policy before your application is accepted by Friends Provident International on normal terms, or Friends Provident International receives your acceptance of any revised terms. We also need to have received your first premium payment or a completed Banker s standing order, Interbank giro or Credit card authority. Effective date (DD/MM/YYYY) Part 5: Residential and travel details 1 What are your nationalities? Please list all. First (or only) life assured 2 Country of birth 3 Town of birth 4 What is your current country of residence? 5 What is the legal basis of your stay in the current country of residence (e.g. permanent resident visa)? 6 How long have you lived in your current country of residence? How long do you intend to stay in your current country of residence? If you intend to change your country of residence, please provide full details. Years Months Years Months Years Months Years Months 8 Friends Provident International Global Term Application form

9 Part 5: Residential and travel details (continued) 7 In which countries have you lived and for how long? First (or only) life assured 8 Has your occupation involved travel outside your current country of residence in the last two years? If Yes, please give details including specific countries visited, dates and duration of stay. 9 Do you expect your occupation to involve travel outside your current country of residence in the future? If Yes, please give details including specific countries visited, dates and duration of stay. Part 6: Recreation details To qualify for non-smoker status rates, you must not have used any form of tobacco or nicotine products within the last 12 months. 1 Have you ever smoked or used any form of tobacco (for example, cigarettes, cigars, pipe tobacco, shisha pipe) or nicotine product (for example, nicotine patches, nicotine gum) in the last 12 months? First (or only) life assured (Random tests may be carried out to verify non-smoker status) If Yes, what form, e.g. cigarettes? How many, e.g. 20 per day? per day per day If you have given up, when did you last use tobacco? (DD/MM/YYYY) What form, e.g. cigarettes? How many, e.g. 20 per day? per day per day 9

10 Part 6: Recreation details (continued) 2 Do you drink alcohol? First (or only) life assured If Yes, how many units per week? units per week units per week (1 unit = a single measure of spirits or 1 glass of wine (125ml) or 1 2 pint of beer (250ml) Have you ever been advised by a doctor or any other medical practitioner to reduce or stop your alcohol consumption on medical grounds or have you ever taken part in counselling, therapy or a programme with the aim of reducing or stopping your alcohol consumption? If Yes, please give details. 3 In the last 7 years have you taken any non-prescription drugs (for example, LSD, ecstasy, cocaine, heroin, cannabis, anabolic steroids, etc.)? If Yes, please give details. 4 Do you take part in any hazardous sport or pastime or do you intend to start? (Mountaineering, motor sport, sub-aqua diving and private flying are examples but you should include any activity that is hazardous. You do not need to include sports such as horse riding, skiing, football, rugby, hockey, cricket or racquet sports.) If Yes, please give details. 10 Friends Provident International Global Term Application form

11 Part 7: Financial details First (or only) life assured 1 Please give your annual earned income. Currency, e.g. SGD Currency, e.g. SGD Amount Amount 2 Please provide details of any existing life, disability or critical illness insurance on your life. Please continue at the end of this document, if necessary. First (or only) life assured a Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy b Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy c Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy d Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy 11

12 Part 7: Financial details (continued) a Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy b Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy c Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy d Type of cover (e.g. Life, Critical Illness, etc.) Country of insurance Name of insurer Sum assured Currency Amount Start date and term (DD/MM/YYYY) Term Years Reason for policy 12 Friends Provident International Global Term Application form

13 Part 7: Financial details (continued) Are any of these policies to be cancelled once this application is in force? First (or only) life assured If Yes, please give company name. Please give policy reference. We may request evidence of earned income due to the level of cover in existence. Examples of evidence includes latest tax statement, statement from employer and last three month s payslip. 3 Apart from the above, have you applied to any other company for life, disability or critical illness insurance in the last 12 months or are you about to do so? If Yes, please give company name. Please give date of application. (DD/MM/YYYY) Sum assured Currency Amount Currency Amount Please give reason for policies. Is only one application to proceed? 4 Have you ever applied for life assurance, insurance against critical illness or income protection/disability insurance and been turned down or asked to pay a higher premium or have other special terms been imposed? If Yes, please give company name. Please give date of application. (DD/MM/YYYY) Sum assured Currency Amount Currency Amount Please give reason for adverse decision. 13

14 Part 7: Financial details (continued) 5 Please complete one section from either a) personal cover or b) business protection. Please complete each appropriate section. a) Personal cover Personal protection (i.e. family cover) Please tick if required. Please tell us the relationship of any dependants. First (or only) life assured Please tell us the ages of any dependants. Years Years Years Years Please contact Friends Provident International to discuss requirements for sums assured greater than USD 4m or equivalent currency. Personal loan protection (including mortgage) Please tick if required. What is the reason for the loan? If it is for a mortgage, please tell us whether it is for your own main residence or investment. Name of lender Amount and duration of loan Amount Duration Months Is the loan conditional on issue of this policy? Yes No b) Business protection Business protection Please tick if required. This includes keyman protection, partnership or shareholder protection or a loan taken out by or on behalf of a business. What is the reason for the cover and how was this sum assured derived? 14 Friends Provident International Global Term Application form

15 Part 8: Family history Before the age of 60, have any of your natural parents, brothers or sisters had, or died from, heart disease, stroke, diabetes, cancer, Huntington s disease, polycystic kidney disease, polyposis of the colon, multiple sclerosis, Alzheimer s disease, Parkinson s disease, motor neurone disease, muscular dystrophy or any hereditary disorder not already listed above? First (or only) life assured Yes No Yes No If Yes, please complete the relevant section(s) below with details of any of the conditions listed above. Please state the age at onset of the medical condition and in the case of cancer, which part of the body was first affected. First (or only) life assured Relationship to you of person affected Medical condition Age at onset of condition 15

16 Part 9: Health questions You are not required to complete this section if a routine medical examination is required. Please go direct to Part 10. All the questions we ask are relevant and important. You must answer them accurately and completely to the best of your knowledge. If you do not, we will have the legal right to cancel any protection cover issued as a result of your application and not to pay any claim. If the answer to any question is Yes, please give full details disclosing all facts as they can influence the assessment and acceptance of the application. First (or only) life assured 1 What is your height? ft in or cm ft in or cm What is your weight? st lbs or kg st lbs or kg Have you lost more than 1 stone or 6 kilograms in the last 6 months? If Yes, please provide details. 2 Do you currently have or have you ever had any of the following: a) Cancer, leukaemia, Hodgkin s disease, lymphoma or any tumour? b) Any lump, cyst or growth that has appeared or grown in size, or a mole or freckle that has bled, caused pain or changed in appearance? c) Heart disease, angina, a heart attack, heart abnormality or defect, heart valve disorder or an irregular heart beat, chest discomfort or pain, disease of or any other disorders of the heart or blood vessels? d) Raised blood pressure or raised cholesterol for which treatment, further readings or a change in diet were advised? e) A stroke, mini stroke, transient ischaemic attack (TIA) or a brain or subarachnoid haemorrhage? f) Multiple sclerosis, Parkinson s disease, Alzheimer s disease, paralysis or paraplegia? g) Visual disturbance, blurred or double vision, optic or retrobulbar neuritis? 16 Friends Provident International Global Term Application form

17 Part 9: Health questions (continued) h) Any impairment of vision, speech or hearing or any disorder of the eyes or ears? (You may ignore sight problems corrected by glasses or contact lenses but you must tell us about all hearing problems, even if corrected by hearing aid(s).) i) Tingling, pins and needles, numbness, weakness of limb, a tremor or any loss of feeling, balance or coordination, for which you consulted a doctor or hospital? j) Recurrent headache for which you have consulted a doctor or any epilepsy, seizure, fit or blackout? k) Diabetes, thyroid disorders or any other endocrine disorder? First (or only) life assured l) Have you ever tested positive for HIV, hepatitis B or C or are you awaiting the results of such a test? (If the result was negative, the fact of having an HIV test will not in itself have any effect on your acceptance terms for insurance.) m) Treatment or a positive test for any disease which was transmitted sexually? n) Gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach or bowel disorders? o) Jaundice, hepatitis, liver disorder or gall bladder disorder? p) Blood, protein or sugar in the urine, kidney stones, infection or any other disorders of the kidneys, bladder or genital organs? q) Anaemia or any other disorders of the blood? r) Asthma, bronchitis, tuberculosis, pneumonia, coughing with blood or any chest, lung or breathing disorder? 17

18 Part 9: Health questions (continued) s) Back pain, neck pain, sciatica, joint pain, arthritis, repetitive strain injury, gout or any other disorder of the muscles, bones or limbs for which you have consulted a doctor, hospital, physiotherapist, osteopath, chiropractor or any other type of medical practitioner or for which you have taken time off work? t) Any mental illness or eating disorder or have you attempted self-harm or taken an overdose? u) Any other feeling of depression, anxiety, stress or fatigue that you have reported to a doctor, hospital, nurse, psychologist or psychiatrist or any other type of medical practitioner? Female only v) Irregular or painful or unusually heavy menstruation, fibroids, cysts or any other disorder of the female organs? First (or only) life assured Question reference If you answered Yes to any of the questions above, please give details in this box to include disorder(s), date of disorder(s), duration, treatment, results of investigations, time off work and when. Are you: First (or only) life assured Name(s) of clinic/ hospital attended Address(es) of clinic/hospital attended Telephone number(s) Fax number(s) 18 Friends Provident International Global Term Application form

19 Part 9: Health questions (continued) First (or only) life assured 3 In the last five years, other than for those conditions you have already mentioned: a) Have you been exposed to the risk of HIV infection? (HIV can be caught through unsafe sex, intravenous drug abuse, or blood transfusions outside Singapore or surgery undertaken outside Singapore.) b) Have you had any medical consultation (for example, with a doctor, consultant, psychiatrist, clinic, physiotherapist or any other type of medical practitioner) or attendance at a hospital as an in-patient or out-patient? c) Have you had, or been advised to have, any medical investigation, x-ray, scan or test? (For this question, you do not need to give details of occasional consultations with your regular doctor for colds, flu, or consultations for oral contraceptive pills, smear tests, well man/woman check-ups where the results are known and were normal.) Question reference If you answered Yes to any of the questions above, please give details in this box to include disorder(s), date of disorder(s), duration, treatment, results of investigations, time off work and when. Are you: First (or only) life assured Name(s) of clinic/ hospital attended Address(es) of clinic/hospital attended Telephone number(s) Question reference If you answered Yes to any of the questions above, please give details in this box to include disorder(s), date of disorder(s), duration, treatment, results of investigations, time off work and when. Are you: First (or only) life assured Fax number(s) Name(s) of clinic/ hospital attended Address(es) of clinic/hospital attended Telephone number(s) Fax number(s) If you need more space to write your answers, please use the section headed Additional information on page

20 Part 9: Health questions (continued) 4 In the last 12 months have you been prescribed any drug, medicine or tablet, or have you had any other form of medical treatment (for example, physiotherapy, psychotherapy)? 5 In the last 6 months have you had any medical symptom, change in your physical or mental health or change in your physical or mental ability for which you have not consulted a doctor, hospital or medical practitioner? (For this question, you do not need to give details of colds and flu which have lasted less than 2 weeks in total.) 6 In the next 12 months are you due to have any consultation or check-up in connection with any medical symptom or condition, or are you waiting for the result of any medical investigation? 7 Other than the information you have already provided, have you ever had an illness or medical condition that has lasted more than 3 months and which affected your ability to study or perform normal daily activities or for which you took more than 2 weeks off work? First (or only) life assured 20 Friends Provident International Global Term Application form

21 Part 9: Health questions (continued) Question reference If you answered Yes to any of the questions above, please give details in this box to include disorder(s), date of disorder(s), duration, treatment, results of investigations, time off work and when. Are you: First (or only) life assured Name(s) of clinic/ hospital attended Address(es) of clinic/hospital attended Telephone number(s) Question reference If you answered Yes to any of the questions above, please give details in this box to include disorder(s), date of disorder(s), duration, treatment, results of investigations, time off work and when. Are you: First (or only) life assured Fax number(s) Name(s) of clinic/ hospital attended Address(es) of clinic/hospital attended Telephone number(s) Fax number(s) Please use the Additional information section below for any further information. Please ensure you give the question reference. Question Additional information (Please state if you are the First or in your answer.) If you require more space to write your answers, please attach an additional sheet to this application. Additional sheet attached Yes No 21

22 Part 10: Applicant(s) details The applicant(s) is/are the person(s) who are to be the owner(s) of the policy. Is/Are the applicant(s): The first or only life assured*? The second life assured*? Both lives assured*? *Please complete questions 19, Neither life/lives assured? If neither, please complete Part 10 in full. Company** Trust** **For Company/Trust, please complete Part 10 in full. Kindly note that additional information and documents will be required during the application process. For example: proof of identity and address. First (or only) applicant Second applicant 1 Title Mr Mrs Miss Ms Mr Mrs Miss Ms Other Other 2 Surname (as shown on NRIC or passport) 3 First name(s) (as shown on NRIC or passport) 4 Aliases If Yes, please specify 5 Company/Trust name (if applicable) 6 Unique identification number (NRIC or passport) 7 Country of birth 8 Current residential address (including street name, town and area code, if known) 22 Friends Provident International Global Term Application form

23 Part 10: Applicant(s) details (continued) First (or only) applicant 9 Please list all contact details below. Contact details Second applicant Home telephone number (mandatory) Office telephone number (mandatory) Mobile number (mandatory) address (mandatory) 10 Nationality (all nationalities to be advised, if more than one) 11 Marital status Single Married Widowed Single Married Widowed 12 Date of birth (DD/MM/YYYY) Divorced Other Divorced Other 13 Please tell us where you were born. Town Town Country Country 14 Country of permanent residence (if different from above) 15 Occupation (If retired, please state former occupation.) 16 Nature of business 17 Employer s name 18 Please give your annual earned income Currency, e.g. SGD Currency, e.g. SGD Amount Amount 19 Are you or any immediate family member or Beneficial Owner previously or currently entrusted with prominent public functions* in Singapore or a foreign country; or a close associate** of one who is/was entrusted with prominent public functions in Singapore or a foreign country? If Yes please provide details: Name of the person previously or currently entrusted with prominent functions Your relationship to the person listed above * Prominent public functions includes the roles held by a head of state, a head of government, government ministers, senior civil or public servants, senior judicial or military officials, senior executives of state owned corporations, senior political party officials, members of the legislative and senior management of international organisations***. ** Close associate means a natural person who is closely connected to a politically exposed person****, either socially or professionally. *** International organisation means an entity established by formal political agreements between member countries that have the status of international treaties, whose existence is recognised by law in member countries and which is not treated as resident institutional unit of the country in which it is located. **** Politically exposed person is a natural person who is entrusted with prominent public functions. 23

24 Part 10: Applicant(s) details (continued) First (or only) applicant Second applicant 20 Purpose and intended nature of insurance application. 21 Relationship or nature of interest in the person(s) named in Part 2 22 Are you the ultimate Beneficial* Owner(s) of this policy? (If the answer is Yes, you do not need to complete questions 23 to 34.) 23 Title Mr Mrs Miss Ms Mr Mrs Miss Ms Other Other 24 Surname (as shown on NRIC or passport) 25 First name(s) (as shown on NRIC or passport) 26 Aliases If Yes, please specify 27 Unique identification number (NRIC or passport) 28 Current residential address (Please provide a certified copy of the Beneficial Owner s verification of address document.) 29 Date of birth (DD/MM/YYYY) 30 Nationality (all nationalities to be advised, if more than one) 31 Relationship to the policyholder 32 Home telephone number 33 Mobile number 34 Work telephone number 24 Friends Provident International Global Term Application form

25 Part 10: Applicant(s) details (continued) Additional information Please let us know, in the space below, of any additional information about the Beneficial Owner(s) we need to be aware of relating to this application. If there are more than two Beneficial Owners, please also provide their details in the space below. * Beneficial Owner, as defined in the MAS Notice 314 on Prevention of Money Laundering and Countering the Financing of Terrorism, means the natural person who ultimately owns or controls the customer or the natural person on whose behalf business relations are established and includes any person who exercises ultimate effective control over a legal person or legal arrangement. To avoid confusion and doubt, Beneficial Owner does not mean the nominated beneficiary(ies) under the policy. If you require more space to write your answers, please attach an additional sheet to this application. Additional sheet attached Yes No 25

26 Part 11: Access to existing medical reports Please note we might not contact your doctor. Even if we do, you must still disclose all the facts when completing this application form. We may need to get medical reports to support your application. Before we can ask any doctor that you have consulted to fill in a report, we need your permission. You do not need to give your permission, but if you do not, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance. We ask your doctor not to reveal information about: Negative tests for HIV, hepatitis B or C; or Any sexually-transmitted diseases unless there could be long term effects on your health. The information you and your doctor provide about your health may result in us: Refusing to provide insurance; Increasing premiums above standard rates; Applying an exclusion to the cover; or Setting premiums at standard rates. If you have any questions relating to the process of getting, assessing or storing medical information, please write to: The Chief Medical Officer, c/o Friends Provident International Limited, Warner House, Castle Street, Salisbury, England, SP1 3SH. Part 12: Personal Data Protection Consent Declaration (Personal Data Protection Act 2012 (PDPA)) Friends Provident International is committed to protecting the privacy of its customers. Friends Provident International will only collect, store, use or disclose your personal data in accordance with the PDPA and this Personal Data Protection Consent Declaration. It is compulsory to provide all of the personal data requested on this form. Failure to provide all the personal data requested on this form may mean that we are unable to process your application. In our usual operations to provide and service your Global Term policy we make use of and disclose your personal data as explained below. General Purposes for the collection, storage, use and disclosure of personal data I/We consent to the personal information to be collected or held by Friends Provident International (whether contained in this application or otherwise) and to be used and/or disclosed by Friends Provident International for the following purposes: i) for identifying me/us; ii) for confirming the accuracy of information collected or received; iii) to process the policy application form, including underwriting purposes; iv) to issue and administer the policy; v) to provide me/us with regular information about the policy; vi) to assess and process any claims made under the policy; vii) for research, customer analysis, data matching and statistical purposes; viii) to provide general information on product enhancements and services which are relevant to me/us; ix) to transfer information to, and to communicate with government authorities such as the Monetary Authority of Singapore, the Singapore Deposit Insurance Corporation Limited and any industry association such as the Life Insurance Association of Singapore, to allow these parties to carry out their regulatory functions or such other functions that may be assigned to them from time to time and are reasonably required in the interest of the insurance industry; x) to meet any disclosure requirement imposed by any local or foreign law or court order which is binding on Friends Provident International or any Aviva group company or pursuant to guidelines issued by regulatory or other relevant authorities which Friends Provident International is expected to comply with; xi) to communicate with me/us, my/our financial adviser and investment adviser whether directly or indirectly for any purpose; and xii) to supply the details or provide a copy of the information to any financial services company wherever they are situated to enable the purchase of assets requested to be linked to the policy. I/We consent to be contacted for research, or customer analysis purposes unless this box is ticked. Please note that, if this box is left blank, I/we understand that I/we can be contacted for research or customer analysis purposes. Disclosures of personal data For the above listed purposes, Friends Provident International will transfer personal data to the following third parties whether based within or outside of Singapore: i) companies within the Aviva group; ii) my/our financial adviser, investment adviser, and/or discretionary fund manager and custodian; iii) companies carrying on reinsurance related business; iv) banks and other financial institutions for the collection or refund of any monies due or payable; v) professional advisers, IT service providers, mailing houses or other third party service providers providing services to Friends Provident International; 26 Friends Provident International Global Term Application form

27 Part 12: Personal Data Protection Consent Declaration (Personal Data Protection Act 2012 (PDPA)) (continued) vi) medical organisations, medical examiners and practitioners, insurance offices, reinsurers or investigators; vii) any regulatory, government or statutory body; and viii) dispute resolution bodies authorised to resolve disputes regarding my/our policy. Where personal information is provided to third parties, we will require them to protect the information in a manner that is consistent with our privacy policies and practices. Marketing purposes Friends Provident International would like to let you know about other products and services available from Friends Provident International that may interest you. Friends Provident International would also like to contact you to conduct consumer research, marketing related or other similar research and analysis (marketing purposes). For these marketing purposes, Friends Provident International will provide your personal information to its professional advisers, IT service providers, mailing houses or other third party service providers providing services to Friends Provident International. Friends Provident International and these third party service providers will collect, use, disclose, store, retain and/or process your personal information for marketing purposes. Should you wish to receive such information and consent to your personal information being provided to third parties and processed by them for the above marketing purposes, please tick this box. Should you wish to receive information, please tick the below boxes to indicate how you would like to receive information about promotions and offers. I/We would like to receive information about promotions and offers by: First (or only) life assured Post Phone SMS Post Phone SMS First (or only) applicant Second applicant Post Phone SMS Post Phone SMS i) I/We understand and agree that I/we shall update Friends Provident International immediately on any changes of my/our personal information and any other information provided in relation to this policy. ii) I/We have read and understood the Data Protection Declaration on page 25. You may change your mind and withdraw your consent to receive direct marketing communications at any time. You may do this by writing to the Chief Executive, Friends Provident International Limited (Singapore Branch), 4 Shenton Way, #11-04/06, SGX Centre 2, Singapore You have the right to access and to request correction of any personal information concerning you held by Friends Provident International. In accordance with the PDPA, Friends Provident International has the right to charge a reasonable fee for the processing of any data access request. Such request or notice can be made in writing to the Chief Executive at the above address, or, to the Data Protection Officer at Royal Court, Castletown, Isle of Man, British Isles IM9 1RA. If a material fact is not disclosed in this application, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to the financial adviser but was not included in the application. Please check to ensure that you are fully satisfied with the information declared in this application. Signature(s) First (or only) life assured (who will also be the applicant if Part 10 is not completed) (who will also be the applicant if Part 10 is not completed) Name (please print) Date (DD/MM/YYYY) Application must be received by Friends Provident International within six weeks of the date of signing. Signature(s) Only complete the following if Part 10 completed. First (or only) applicant (if applicable) Only complete the following if Part 10 completed. Second applicant (if applicable) Date (DD/MM/YYYY) 27

28 Part 13: Declaration This Declaration must be signed by all persons involved in this application. Global Term is underwritten by Friends Provident International Limited Singapore Branch (Friends Provident International). Each policy will be entered in the register of Singapore policies. This application is my official request to enter into a contract with Friends Provident International together providing the foregoing policy. I understand and accept that the contract will be on Friends Provident International s normal terms and conditions. I understand and accept that Friends Provident International is subject to the supervisory arrangements and laws of Singapore. I understand that the policy shall be governed by the laws of Singapore. I understand and accept that this application can only be accepted by employees of Friends Provident International situated at 4 Shenton Way, #11-04/06, SGX Centre 2, Singapore and that no other employees or third parties have the necessary authority to create a binding contract. I acknowledge that in the event of any premium tax or withholding tax being levied in the my country of residence, it will be my responsibility to increase the premium by an appropriate amount or to settle the liability directly with the relevant tax authorities. I am aware that deliberate tax evasion is a criminal offence. I am responsible for my own tax affairs and I hereby declare that I understand my personal tax obligations and responsibilities and I have complied with all legal requirements to make declarations to tax authorities and pay the tax that I owe. As appropriate and necessary I have taken, or will take, legal advice in relation to my tax affairs and in particular, my tax obligations, as they apply to this application. I understand and accept Friends Provident International may require sight of my medical records to consider a claim. I authorise any doctor, physician, practitioner, hospital, clinic, insurance or reinsurance company, employer, other individual organisation or government office that has any records or knowledge of me or my health to disclose to Friends Provident International any information for the purpose of considering a claim. This authorisation shall irrevocably bind my successors and assigns and remain valid, notwithstanding my death or incapacity, and a copy of this authorisation shall be as effective and valid as the original. I understand that information given to Friends Provident International in connection with this application may be used by Friends Provident International in its consideration of any claim in future and may be shared with a third party, e.g. medical examiner, to help in the assessment of a claim. I understand that Friends Provident International will pass the information about any claim concerning critical or disability illness insurance to the Association of British Insurers (ABI) so that they can make it available to other insurers. I also understand that, in response to any searches you make in connection with this claim, the ABI may pass you information it has received from other insurers. I am satisfied that to the best of my knowledge and belief I am not subject to any legislation which would make this policy unlawful. I understand and accept that the terms and conditions and a copy of this completed application are available on request. I understand and accept that where I am applying on the advice of a financial adviser, that adviser is acting on my behalf and not as an agent of Friends Provident International. I acknowledge that Friends Provident International and my financial adviser have entered into an agreement ( terms of business ) which sets out the basis upon which Friends Provident International is prepared to accept applications submitted by the financial adviser on my behalf. This agreement categorically states that the financial adviser acts as my agent, and not the agent of Friends Provident International. I understand that Friends Provident International will report this business in its register of Singapore policies. I have read Part 1 General Information and my answers to the questions in this application and declare that, to the best of my knowledge and belief, all the information I have given is true and that no fact has been withheld. I understand I must ensure that all facts I disclosed to my financial adviser in answer to the questions in this application are accurately recorded in this application. I understand and accept that failure to disclose a fact or the giving of false information will give Friends Provident International the right to cancel from inception any policy issued as a result of this application and may invalidate any future claim. I understand that I must tell Friends Provident International without delay if my health or circumstances change before Friends Provident International assumes risk for the policy applied for. I accept that if I am required to have a medical examination, the replies to the medical examiner s questions will form part of this application. I agree Friends Provident International will collect, store, use or disclose the information I give (as well as information about me relating to any existing policy I may have with Friends Provident International) for administration, underwriting, claims, research and statistical purposes and any other purpose as stated in the Personal Data Protection Consent Declaration above. I authorise Friends Provident International to pass information including medical information to medical examiners and practitioners, underwriters, claims investigation companies, life insurance or reinsurance companies, data processors and to any company or agency appointed for these purposes. (These companies or agencies may be located in countries that do not have laws to protect your personal information. Friends Provident International will remain responsible for making sure that the information is held securely.) I also agree Friends Provident International may pass the information to third parties for the prevention of crime or detection of fraud, enabling assets to be rightfully claimed or where required by law or regulation. 28 Friends Provident International Global Term Application form