Personal Accident and

PRUwellness Form
REMINDERS: PRU LIFE INSURANCE CORPORATION OF U.K.
Please use CAPITAL LETTERS and black ink. 9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
Tick the appropriate box to indicate your choice. 1634 Taguig City, Philippines
Please do not sign on a blank form. Customer helpdesk: (632) 8683 9000, (632) 8884 8484, (632) 8887 LIFE
If not applicable, put “N/A” in all empty fields. within Metro Manila, 1 800 10 PRULINK for domestic toll-free
Email: [email protected] Website: www. prulifeuk.com.ph

PW0000001
AGENT INFORMATION (FOR AGENT’S USE ONLY)
SURNAME, GIVEN NAME AGENT CODE BRANCH

(Accomplish this section only if the Policyowner is

DETAILS OF LIFE INSURED DETAILS OF POLICYOWNER different from the Life Insured)

SURNAME SURNAME

GIVEN NAME GIVEN NAME

MIDDLE NAME MIDDLE NAME

OTHER LEGAL NAME/ALIAS OTHER LEGAL NAME/ALIAS

GENDER CIVIL STATUS SALUTATION GENDER CIVIL STATUS SALUTATION

Male Single Married Male Single Married
NATIONALITY NATIONALITY
Female Others Female Others

DATE OF BIRTH (mm/dd/yyyy) AGE IDENTIFICATION INFORMATION DATE OF BIRTH (mm/dd/yyyy) AGE IDENTIFICATION INFORMATION
SSS/GSIS TIN SSS/GSIS TIN

PLACE OF BIRTH (City/province, country) OTHERS ID NUMBER PLACE OF BIRTH (City/province, country) OTHERS ID NUMBER

OCCUPATION (State exact duties; if member of AFP/PNP, state rank) OCCUPATIONAL CLASS OCCUPATION (State exact duties; if member of AFP/PNP, state rank) OCCUPATIONAL CLASS
1 2 3 4 1 2 3 4

NATURE OF WORK OR NATURE OF BUSINESS (If self-employed) NATURE OF WORK OR NATURE OF BUSINESS (If self-employed)

EMPLOYER EMPLOYER

NATURE OF BUSINESS OF EMPLOYER NATURE OF BUSINESS OF EMPLOYER

GROSS ANNUAL INCOME (In PhP) SOURCES OF FUNDS GROSS ANNUAL INCOME (In PhP) SOURCES OF FUNDS
Salary Business Remittance Salary Business Remittance

Others Others
(If premium payments come from a third-party payor, please (If premium payments come from a third-party payor, please
accomplish the KYC for Beneficial Owner and Third Party Payor Form) accomplish the KYC for Beneficial Owner and Third Party Payor Form)

MOBILE NUMBER TELEPHONE NUMBER MOBILE NUMBER TELEPHONE NUMBER

EMAIL ADDRESS EMAIL ADDRESS

PRESENT ADDRESS (Number, street, municipality/city, province) PRESENT ADDRESS (Number, street, municipality/city, province)

COUNTRY ZIP CODE COUNTRY ZIP CODE

PAGE 1 PW0000001
 DETAILS OF POLICYOWNER (IF ENTITY)

COMPANY/BUSINESS NAME NATURE OF BUSINESS TELEPHONE NUMBER

TAX IDENTIFICATION NUMBER BUSINESS ADDRESS (Number, street, municipality/city, province) COUNTRY

Please attach the latest General Information Sheet filed with the Securities and ZIP CODE
Exchange Commission for the following: (a) complete list of directors; (b) complete
list of stockholders.

NAME OF AUTHORIZED REPRESENTATIVE POSITION TELEPHONE NUMBER

DETAILS OF LIFE INSURED DETAILS OF POLICYOWNER (Accomplish this section only if the Policyowner is different from the Life Insured)

PERMANENT ADDRESS Tick if same as PERMANENT ADDRESS Tick if same as

present address (Number, street, municipality/city, province) present address
(Number, street, municipality/city, province)

COUNTRY ZIP CODE COUNTRY ZIP CODE

EMPLOYER/BUSINESS ADDRESS Tick if same as EMPLOYER/BUSINESS ADDRESS Tick if same as

(Number, street, municipality/city, province) present address (Number, street, municipality/city, province) present address

COUNTRY ZIP CODE COUNTRY ZIP CODE

In the next 12 months, do you expect to change your: In the next 12 months, do you expect to change your:
a. occupation? Yes No a. occupation? Yes No
b. country/province/city/municipality of residence? Yes No b. country/province/city/municipality of residence? Yes No
If yes to (a) and/or (b), provide details. If yes to (a) and/or (b), provide details.

PREFERRED POLICYOWNER’S ADDRESS FOR CORRESPONDENCES RELATIONSHIP OF POLICYOWNER TO

LIFE INSURED
Present Permanent Business/Employer (Fill this out only if the Policyowner is different from the Life Insured)

DETAILS OF BENEFICIAL OWNER

Beneficial Owner refers to any natural person who ultimately owns or controls the customer, and/or on whose behalf a transaction or activity is being conducted, or has ultimate
effective control over a legal person or arrangement.
In relation to an entity, Beneficial Owner/s are individuals either owning or controlling at least 20% of the entity’s shares or voting rights.
Do you have a Beneficial Owner? Yes No If “YES”, please accomplish the KYC for Beneficial Owner and Third Party Payor Form.

DETAILS OF PRIMARY AND SECONDARY BENEFICIARIES

If any beneficiary designation is “IRREVOCABLE”, please accomplish the Endorsement for Designating Irrevocable Beneficiary Form. If more than one Beneficiary is named, equal
sharing shall be presumed unless stated otherwise.

SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER

Male Female

RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH (City, Country) NATIONALITY
Primary Secondary Revocable Irrevocable

PRESENT ADDRESS (Number, street, municipality/city, province) ZIP CODE Tick if same as Policyowner COUNTRY

MOBILE NUMBER TELEPHONE NUMBER EMAIL ADDRESS

SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER

Male Female

RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH (City, Country) NATIONALITY
Primary Secondary Revocable Irrevocable

PRESENT ADDRESS (Number, street, municipality/city, province) ZIP CODE Tick if same as Policyowner COUNTRY

MOBILE NUMBER TELEPHONE NUMBER EMAIL ADDRESS

If there are more than two (2) beneficiaries, please answer the Supplemental Form for Additional Beneficiaries.

PAGE 2 PW0000001
PROPOSED PLAN DETAILS

Personal Accident PRUwellness

SUPPLEMENTARY CONTRACTS/RIDERS PACKAGE NUMBER
PA Executive PA Power PA Junior PLAN A PLAN B PLAN C
Hospital Income
PA Standard Others: SUM ASSURED
Medical Reimbursement PLAN A+ Others:

PREMIUM INFORMATION
ANNUALIZED PREMIUM INITIAL PREMIUM PAID MODE OF PAYMENT METHOD OF PAYMENT (PREMIUM RENEWAL)
Annual Semi-annual Credit card Auto-debit arrangement Cheque
Quarterly Monthly Post-dated cheque Cash Others

MODE OF RELEASE (FOR TRADITIONAL PLANS WITH PAYOUT AND/OR PLANS WITH DISBURSEMENT)

I hereby authorize Pru Life UK to release the annual payouts or disbursement through:

FUND TRANSFER

BANK NAME

ACCOUNT NAME

Note: This account should belong to you. Third party accounts are not allowed.
CURRENCY PHP USD
ACCOUNT NUMBER ACCOUNT TYPE SAVINGS CHECKING

Fund transfers to Peso bank accounts which are PESONet participants are free of charge. For Philippine peso payouts, please elect a Philippine Peso account.

If proceeds are more than PHP 1,000,000, please provide proof of ownership of the bank account (e.g., photocopy/picture of bank account passbook, deposit slip, or
statement of account).

QUESTIONS APPLICABLE TO LIFE INSURED

Have you ever had:
1) consultation, confinement, surgical operation, or treatment for any illness or injury? If yes, please provide full details including the name(s) and Yes No
addresses of any doctors consulted or hospital where you were confined in the space provided below.
2) diagnostics tests such as x-rays, ultrasonogram, blood test, CT scan, MRI, ECG, biopsy, urine or other investigation other than for routine employment
Yes No
purposes? If yes, please indicate the diagnostic tests taken, their purpose/s, and results in the space provided below.

3) What insurance(s) is/are now in force on the life of Life Insured? Company Amount of coverage Rider(s)/Year issued

4) Has there been or will there be any change in any existing insurance in force? Yes No NOTE: If answered “YES” to questions 4 and/
or 5, please accomplish the Replacement
5) Will premiums for the insurance applied for be paid by a policy loan from any existing policy? Yes No Notification section in the next page.

DECLARATION OF UNDERSTANDING
PLEASE READ CAREFULLY BEFORE SIGNING THE APPLICATION FORM:
By signing this Application, I, (i.e. each of the Policyowner and Life Insured) declare, agree to, and authorize the following:

1. I understand that Pru Life UK is an insurance company authorized to provide insurance products or services in the Philippines as regulated by the Insurance Commission. I confirm that during the application process, I only
dealt with an agent/insurance broker that is recognized by the Company and licensed to sell insurance policies, whether traditional or investment-linked in nature, by the Insurance Commission.

2. All the statements and answers in this Application and any information given to Pru Life UK or its medical examiners, including any amendments, are complete, true, correct, and binding on all parties in interest
under the Policy applied for.

3. Pru Life UK reserves the right to request for additional medical evidence to assess my health. Any physician, hospital, clinic, or medical organization is authorized to furnish Pru Life UK with any medical information
pertaining to me.

4. Prior to the issuance of the Policy applied for, I agree to inform Pru Life UK of any change in my (a) state of health, and (b) occupation or activities.

5. The insurance coverage will not commence until this Application has been approved, the initial premium has been received by Pru Life UK, and the Policy has been issued while I am in good health.

6. I will update Pru Life UK in a timely manner of any change in details previously provided especially with respect to a change in citizenship, tax status, or tax residency, correspondence address, or contact numbers, both local and
foreign. If the Policyowner is a corporation, changes in registered address, address of place of business, substantial shareholders, legal or beneficial owners who own or control at least 20% of the Policyowner will also be
disclosed.

7. Non-payment of premiums, misrepresentation or non-disclosure of material information, and/or violation of any of the terms or conditions of the Policy may lead to the denial or cancellation of insurance coverage by Pru Life UK.

8. I confirm that I received the benefit illustration, quotation proposal, product summary, or other relevant sales materials and that the terms and conditions of the insurance policy that I applied for were clearly explained to me
and fully understood prior to my signing the Application and accepting insurance coverage. Moreover, questions and clarifications on my end, if any, were properly and fully addressed.

9. I understand that I can conduct additional research and compare available options in the market before agreeing to purchase an insurance policy that best suits my needs and requirements from Pru Life UK.

10. I confirm that I am of sound financial health and agree to pay the required insurance premiums on time or within the grace period indicated in the Policy.

11. The amounts to be invested in the Policy have been declared to relevant tax authorities and were not derived, directly or indirectly, from illegal activities or sources and/or tax evasion.

12. This Application and any policy issued pursuant to it shall be subject to all laws, regulations, resolutions and guidelines on financial underwriting, anti-money laundering, counter terrorist financing and financial and economic
sanctions regimes (“Issuances”). In the event that Pru Life UK is unable to comply with such Issuances, including the relevant Customer Due Diligence ("CDD") measures as required under the Anti-Money Laundering Act, as
amended, due to any act or omission on my part, Pru Life UK may (i) disapprove this Application; (ii) apply measures to restrict the services available or prohibit any further transactions on the Policy; and (iii) in case such measures
are unsuccessful, terminate the business relationship. In the event of termination, any refund of premiums or payment of withdrawal value shall be subject to the terms of the Policy. I am bound by obligations set out in relevant
United Nations Security Council Resolutions relating to the prevention and suppression of proliferation financing of weapons of mass destruction, including the freezing and unfreezing actions as well as prohibitions from
conducting transactions with designated persons and entities.

PAGE 3 PW0000001
13. If this Application is declined by Pru Life UK, its only obligation is to return the premium paid. If the Application is cancelled for failure to submit requirements, Pru Life UK will return the premium paid less fees for
medical examinations it incurred.

14. I accept, agree with, and understand the features, benefits, nature, limitations, exclusions, risks, terms, and conditions of the Policy, product and attached riders. For unit-linked products, the next computed unit price following the
issue date of the Policy will be applied. I agree to receive financial and other-policy related information and notifications through the mobile number and email address I have provided to Pru Life UK.

15. I agree to be pre-registered to PRUAccess, an online facility that will enable me to manage and request certain transactions involving my Policy. I acknowledge that Pru Life UK shall not be liable for claims or liabilities incurred as
a result of the dissemination of my personal information through the said facilities. I understand that if I no longer wish to receive such information or notification through email or mobile and/or be registered to PRUAccess, I
may contact Pru Life UK at telephone numbers (632) 8887 LIFE (8887 5433) for Metro Manila and 1800 10 PRULINK (1 800 10 7785465) for domestic toll-free, or email [email protected].

16. If Pru Life UK approves my Application, my Policy Data Page will be sent to my email address on record and the electronic copy of my Policy will be available in PRUAccess. The date that my Policy Data Page is sent via email shall
be considered as my Policy Receipt Date and the 15-day cooling off period will begin on this date. I acknowledge that I may view all other policy documents and review and manage my Policy via PRUAccess.

17. I hereby give consent to receiving an electronic copy of the policy contract, as approved, in lieu of a physical copy thereof. Further, understand that should I wish to receive a physical copy, I can reach out to Pru Life UK
through [email protected] to request for the same upon payment of appropriate fees.

18. Upon approval by Pru Life UK of this Application, Pru Life UK will provide insurance coverage in accordance with the Policy, and therefore will charge insurance premiums necessary to provide that coverage.

19. Pru Life UK ensures that its employees, agents and partner insurance brokers are qualified, experienced, ethical, duly licensed and registered, and have undergone sufficient training on Pru Life UK's products and services to enable
them to provide fair and sound advice. It also adheres to the prescribed and best industry standards when dealing with its customers through answering queries, giving recommendations, processing claims, paying benefits in a
timely manner, and the like.

20. When processing claims, Pru Life UK may conduct investigations to prevent fraudulent claims and ensure that the beneficiaries receive the correct payout according to the terms of the Policy.

21. Pru Life UK adheres to existing laws, rules and regulations.

DATA PRIVACY
For purposes of this Section:
a. “Pru Life UK” shall refer to Pru Life Insurance Corporation of U.K., its directors, officers, employees, insurance agents, insurance brokers, other agents and representatives, reinsurers, contractors, legal advisers, and Pru Life UK’s
subsidiaries, affiliates and other related entities, and their directors, officers, employees, insurance agents, insurance brokers, other agents and representatives, contractors, and legal advisers.
b. “Data Subject” shall mean the Policyowner, the Life Insured, the Beneficial Owner, Beneficiaries, and all other individuals whose personal information or sensitive personal information is or will be disclosed to Pru Life UK.

Purpose Statement:

The information provided by you in this application form will be used for general data processing to be done by Pru Life UK for the issuance, implementation and handling of insurance policies, risk assessment,
underwriting and administration of insurance coverage and claims, provision of any service, data analytics, any legitimate interest of Pru Life UK, or any purpose permitted or required by applicable law.
This processing may be either manual or automated and within or outside of the Philippines.

To enable Pru Life UK to effectively address insurance requirements and provide better service, your personal information may also, upon your explicit consent, be used for profiling, automated decision-making,
and direct marketing, which includes products and other offers.

During processing, we may share the information you provided to our authorized data processors to whom we outsource the processing of your information for your policy, including couriers and contractors for
anti-money laundering systems, claims investigations and processing, risk assessment, photocopying, scanning, indexing and printing services, and other value-added services.

Our collection and processing of your personal data, including any sensitive personal information, is based on your application for insurance and other related services, any contract we may enter into with you,
our legitimate interests, or a requirement under applicable law. Any information collected may be retained by Pru Life UK and our authorized data processors until ten (10) years from the date of maturity or
termination of the policy or date of denial of this application, whichever comes earlier.

We may share your information with governmental and other regulatory authorities, or self-regulatory bodies in various jurisdictions as required or allowed by applicable laws and regulations, including the
Medical Information Database administered by the Philippine Life Insurance Association, Inc. In accordance with the Insurance Commission’s Circular Letter No. 2016-54, your medical information will be
uploaded to a Medical Information Database accessible to life insurance companies for the purpose of enhancing risk assessment and preventing fraud. Once uploaded, all life insurance companies will only
have limited access to your information in order to protect your right to privacy in accordance with law. A copy of Circular Letter No. 2016-54 may be accessed at the Insurance Commission’s website at
http://www.insurance.gov.ph/.

For more information about your rights as a data subject and how we protect your information, you may access our privacy policy through our website at https://www.prulifeuk.com.ph/en/footer/privacy-policy/.
Should you have any questions or requests in relation to the processing of your personal or sensitive personal information, or your rights as a data subject you may get in touch with our Data Protection Officer
through the following:

• Postal address: 9F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio, 1634 Taguig City, Metro Manila
• Telephone: (632) 8887 5433 for Metro Manila, 1 800 10 7785465 via PLDT landline for domestic toll-free
• Email: [email protected]

By signing this application form:

• You allow Pru Life UK to use, collect and process your personal information and sensitive personal information as specified in the Purpose Statement above, and in accordance with
applicable data privacy regulations.
• You specifically consent to the activities you have checked below:

Automated processing of your personal information which shall be the sole basis of Pru Life UK’s approval or denial of the application.
Receiving Pru Life UK’s promotional offers via email or SMS. You will get up to date information on product features, exclusive products, and other Pru Life UK offers.
You can unsubscribe any time through the contact information provided above.
Using your profile so that we can get a deeper understanding of your preferences and be able to provide you with better products and services.

• You warrant that the consent of the Beneficial Owner (if any), Beneficiaries, and all other data subjects have been obtained for the use, storage and processing of their personal information for purposes of compliance with
regulatory requirements and applicable laws, the processing of this application, and the administration of the policy issued. You also undertake to provide Pru Life UK with proof of your authority to give the required
consents of the other data subjects with respect to the disclosure and processing of their personal information and/or sensitive personal information for the legitimate purposes set out in this application or in the policy
issued by Pru Life UK.

• You agree to indemnify Pru Life UK and hold it free and harmless from any damages incurred by Pru Life UK as a result of any claim filed by any of the data subjects in relation to a breach of any of the warranties above, or
for any damages arising from any misrepresentation made in this application or from any material breach of its provisions.

Signature over printed name of LIFE INSURED Signature over printed name of PARENT/GUARDIAN

Signature over printed name of POLICYOWNER PLACE OF SIGNING DATE OF SIGNING (mm/dd/yyyy)

Signature over printed name of AGENT

PAGE 4 PW0000001
REPLACEMENT NOTIFICATION
REMINDERS: It is usually disadvantageous to REPLACE existing life insurance policy/ies with a new one. Some disadvantages are: (a) you may not be insurable under standard terms; (b) you may have to pay higher premiums
in view of higher age; or (c) you may lose financial benefits accumulated over the years. Please note that in your own interest, we advise that you consult your present insurer before making a final decision. Hear from both sides
and make a careful comparison. You can then be sure that you are making a final decision that is in your best interest.

FULL NAME (Surname, given name, middle name)

DATE OF BIRTH (mm/dd/yyyy)

ADDRESS (Number, street, municipality/city, province)

COUNTRY

NAME OF APPLICANT IF OTHER THAN THE LIFE INSURED (Surname, given name, middle name)

EXISTING POLICIES TO BE REPLACED

INSURED’S NAME (As it appears in the Policy) COMPANY NAME POLICY NUMBER

In connection with my decision to purchase a product from Pru Life Insurance Corporation of U.K. (”Pru Life UK”), I hereby certify the following:

1. My purchase of the (name of product) is a replacement for my existing Policy/ies with Pru Life UK and/or with another insurance company.

2. My agent has disclosed to me the fees and charges that I will bear in switching from my original Policy/ies to the (name of product)(”the Replacement Policy”).I
understand that the fees and charges would include all fees associated with the disposal of or reduction in coverage or interests under my original Policy/ies and/or fees incurred during the purchase of or
increase in coverage or interests under the Replacement Policy.

3. My agent has advised me of the disadvantages (i.e. loss of financial benefits, higher premium, non-insurability, etc.) that I will or may suffer (temporarily or otherwise) as a result of switching
from my original Policy/ies to the Replacement Policy.

Signature over printed name of POLICYOWNER

DATE OF SIGNING (mm/dd/yyyy)

PAGE 5 PW0000001
AGENT’S REPORT AND DECLARATIONS (FOR AGENT’S USE ONLY)

1) Has there been or will there be any change in any existing insurance in force on
Yes No
the life of the Life Insured? (If yes, provide details)

2) Will premiums for the insurance be paid by a policy loan or withdrawal from any
Yes No
existing policy? (If yes, provide details)

3) I confirm that the Policyowner and Life Insured have filled out and signed the
Yes No
Application Form in my presence.

4) Other details/additional remarks

I hereby represent that all of the above statements and answers to all the above questions are complete and true.

Signature over printed name of AGENT DATE OF SIGNING (mm/dd/yyyy)

PAGE 6 PW0000001