APPLICATION FOR TERM INSURANCE
 
SECTION A - PRIMARY INSURED
Insurance History (Insurance in-force on the life of Proposed Insured)
Is the policy applied for intended to replace any existing insurance with NetCare or with any other companies?
SECTION B – OTHER INSURED (If more than one Other Insured, complete separate application)
Insurance History (Insurance in-force on the life of Proposed Insured)
Is the policy applied for intended to replace any existing insurance with NetCare or with any other companies?
SECTION C – APPLICANT/OWNER
SECTION D - BENEFITS & PREMIUM DETAILS
SECTION E – BENEFICIARIES (Unless otherwise indicated, we will take the beneficiary designation as "revocable".)
Primary Insured ( For "Type", please indicate if "Primary" or "Contingent"; if there is no indication, we will take the designation as "Primary")
Other Insured ( For Type, please indicate if Primary or Contingent; if there is no indication, we will take the designation as Primary)
SECTION F – NON-MEDICAL AND MEDICAL DECLARATIONS
(Please indicate complete details of "YES" answers (Indicate doctor’s name, address and contact nos.)):
Primary
Insured
Other
Insured
 
Dependents
1. What is your height? (Indicate in feet and inches)
2. What is your weight? (Indicate in lbs.)
Has/Have the Proposed Insured(s):
Press switches for YES/NO answer
3. Ever had any change in weight in the past year?
4. Ever had any application or reinstatement, which is pending or which was declined, postponed, or modified in amount, plan or rate, with us or any other company? If yes, indicate details including company name
5. Ever engaged in, or contemplated engaging in aircraft flying, skydiving, scuba diving, automobile racing, mountain climbing, or any other hazardous avocation or activities? If yes, indicate details and complete appropriate questionnaire.
6. Stayed in the last 2 years, or intended to travel, work or stay in a country different from now? If yes, indicate which country, purpose, date and duration of stay.
7. Smoked cigarette, or used betel nut or tobacco now or in the past? If yes, indicate type, date & duration, how many per day, and the last time he/she smoked.
8. Ever taken any habit-forming substance, drugs or alcohol, or ever received advice or treatment for such habit or addiction? If yes, indicate the type, amount and frequency.
9. Do you drink alcohol? (Please provide frequency, amount, type and circumstance in "Agent’s Remarks" section)
10. Have you ever used illegal drugs, such as Marijuana, cocaine, heroine or any other illegal drugs?
11. Ever had his/her driver’s license suspended or revoked, or ever had any moving traffic violations or accidents within the last 3 years? If yes, give details and driver’s license number.
12. Ever been arrested, except for traffic violations? If yes, give details
13. Ever had military service deferment, rejection or discharge due to physical or mental condition?
14. Ever applied for or received pension, payment or benefit due to injury, sickness or disability?
15. Ever been refused as a blood donor, or received any blood transfusion or blood products?
16. Ever had any physical defects, lameness, amputation, abnormality or deformities?
17. Ever had or been told to have, or had indication of, or sought consultation for:
 
 
 
   a. Tuberculosis, asthma, emphysema, chronic cough, or any respiratory/lung disease?
   b. Rheumatic fever, high blood pressure, chest pain, palpitations, heart attack, defects of blood vessels, or any disorder of the heart or circulatory system?
   c. Hepatitis, jaundice, intestinal bleeding, ulcer, bowel, liver or gallbladder disease, or any gastrointestinal disorder?
   d. Sugar, protein, blood or pus in the urine, venereal disease, kidney stone or other disorder of the genitourinary or reproductive organs?
   e. Diabetes, thyroid trouble or other endocrine disorder, cancer, cyst, tumor, lumps/abnormal bodily growth,enlarged lymph nodes, skin lesions or any disorder of the skin?
   f. Neuritis, sciatica, rheumatism, arthritis, gout, or any disorder of the muscles, bones, joints, spine or back?
   g. Brain, eye, ear, nose or throat disorder, epilepsy, fainting spells, or any nervous or mental disorder?
   h. AIDS or HIV infection related condition, ually transmitted disease, allergies, anemia or any blood disorder?
   i. Continuous or unexplained symptoms of fatigue, weight loss, diarrhea or frequent severe headaches?
18. Other than above, ever had any examination, treatment, consultation or hospitalization within the past 5 years?
19. Ever had any accident or injury, or ever been under observation or patient in a hospital, sanitarium or any medical facility, or ever had any accident, injury, consultation, medical advice, diagnostic or laboratory test, treatment, or signs and symptoms of any disease or disorder not mentioned above?
20. Are you now under observation or treatment, or currently taking any prescribed drugs or medications?
21. Family History: ever had any family member who suffered from tuberculosis, heart disease, diabetes, high blood pressure, stroke, kidney disease, cancer, mental illness, AIDS or HIV infection, or any communicable or familial disease? Give relation, age at onset, age at death (if applicable) and nature of disease.
22. For WOMEN only
   a. Are you now pregnant? If yes, indicate how many months and number of previous pregnancies
   b. Ever had any complications of childbirth or pregnancy, or abnormal menstruation?
   c. State the date of last menstruation:
SECTION G – CHILDREN’S RIDER INFORMATION

CONDITIONS RELATING TO THIS APPLICATION AND NOTICES

I/We hereby declare that all the foregoing statements, declarations, and answers in this application, including Application for Life Insurance Parts I and II, together with those in any required medical examination, including HIV and other laboratory tests, questionnaire or amendments, are complete and true, and that NetCare Life and Health Insurance, believing them to be such, will rely and act on them, and that they shall form the basis of any insurance policy to be issued hereon, and which together with the policy, shall constitute the entire contract between parties thereto.

I/We understand that:

1. The President, the Secretary, or the Vice-President of NetCare Life and Health Insurance, are the only persons with the authority to bind the Company, except that an agent of the Company has the authority to issue to me/us a Conditional Receipt for the amount of money I/we submit as an offer for a contract.

2. The insurance coverage under this application is subject to the terms and conditions of the insurance policy, and will not be in-force until I/we have paid the first premium in full and a policy has been issued and delivered by the Company

3. If the Home Office makes any change in amount, class, insurance plan, or benefits, the contract will be valid only after I/we sign a written contract effecting those changes.

AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

NetCare Life and Health Insurance, its re-insurers, insurance support organizations, and their authorized representatives, may obtain medical and other information in order to evaluate my/our application for insurance.

to be interviewed if any investigative consumer report is prepared in connection with this

application. I/We understand that I/we am/are entitled to receive a copy of that report, pursuant to the provisions of the Insurance Information and Privacy Act in effect in my/our state of residence.

I/We further authorize my/our employer/s, or any physician, medical practitioner, hospital, clinic or any medically related organization or person to furnish NetCare Life and Health Insurance with any information concerning my/our medical history, including diagnosis, treatment or prognosis with respect to any physical or mental condition, and other non-medical information, including information about drugs and alcoholism.

I/We understand the information obtained through this Authorization will be used by NetCare Life and Health Insurance to determine my / our eligibility for insurance. Any information obtained will not be released by NetCare Life and Health Insurance to any person or organization EXCEPT to reinsuring companies, the Medical Information Bureau Inc., or other persons or organizations performing business or legal service in connection with my/our application, or as may be otherwise lawfully required, or as I may further authorize.

I/We also understand that:

1. I/We may request for a copy of this Authorization.

2. A photographic copy of this Authorization shall be as valid as the original.

3. I have read and understand the conditions of this application, and acknowledge receipt of the Notice to Applicant.

Signed this
Dated at
Signature of Primary Insured
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Signature of Owner/Applicant(If other than Primary Insured)
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Signature of Other Insured Or Spouse(If such rider is applied for)
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Signature of Other Insured(If more than one Other Insured)
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Signature of Title of Officer in Behalf of Firm/Corporation
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