RPT Family CI

Health Start Proposed Insured:
Mr. ALFHADZRY BOLIVAR JUMLI

Age 24, Male, Non-smoker
Policyowner:
Mr. ALFHADZRY BOLIVAR JUMLI
Age 24, Male
Dear ALFHADZRY,
Congratulations! You’ve chosen the right partner to help you have a head-start in protecting your health. AXA
Philippines is a formidable synergy between two financial giants - the AXA Group and the Metrobank Group.
We are happy to share with you the details of your chosen health plan, Health Start . Below is a summary of your
plan and the benefits you can enjoy.
Sum Insured Php 1,000,000
SUMMARY OF BENEFITS
Major Critical Minor Critical Return of Life Insurance Child Cover
Conditions Conditions Premium Coverage Benefit
Receive Receive 20% of the At Age 75, receive In case of the Receive
Php1,000,000 in Sum Insured in a lump-sum insured’s untimely Php200,000 in
case the insured case the insured equivalent to the demise, your loved case your child, if
encounters: encounters any of total premiums you ones will receive any, gets
• Cancer the 9 Minor Critical have paid Php1,000,000 to diagnosed with any
• Stroke Illness Conditions help in taking care of the Child Critical
• Heart of their needs Conditions
Attack
• Terminal
Illness
Notes:
1. The policy terminates after claiming either of the Major Critical Conditions or the Life Insurance Coverage. Life Insurance
Coverage is interchangeably used as death benefit in this proposal, pertains to one and the same benefit.
2. Minor Critical Conditions can be claimed for a maximum of four (4) times throughout the lifetime of the policy and
should be for different conditions, except for carcinoma-in-situ of different organs. The amount of benefit paid or payable
will be deducted from the Major Critical Conditions Benefit and Death Benefit payable under the Basic Plan. Please
refer to the conditions stated on the subsequent pages for the covered illnesses.
3. Return of premium will be LESS any minor critical illness benefit paid and any indebtedness. In case of substandard
rating, return of premium will follow the standard premiums only. For issue age up to 49, this is equivalent to 100% of
total standard premiums paid. For issue age 50 and up, this is equivalent to 50% of total standard premiums paid.
4. Life Insurance Coverage will be LESS any minor critical illness benefits paid, any Return of Premium paid and any
indebtedness.
5. The Child Cover Benefit is provided for any one child who is under 18 years old at the time of claim or first diagnosis.
This benefit is payable only once, on a first child-to-claim basis. Child Cover Benefit is on top of the plan’s sum insured.
6. Major, Minor Critical Conditions and Child Cover Benefit are payable according to the illness definitions as set out in the
policy contract.
Page 1 of 13 of Proposal No. 57923-202302020848-2-02

Printed on: 2/2/2023 8:49:28 PM Created on: 02/02/2023 Expiry Date: 04/03/2023
Version Number: 6.2.0 Date for Next Insurance Age: 08/08/2023
Plan Code: SCI20 / Rider Code: N/A
Health Start Philippine Peso
for: Mr. ALFHADZRY BOLIVAR JUMLI, 24
The succeeding pages of this proposal provide more details on the benefits and features of Health Start.
Again, thank you for your interest in our products. If you have questions, please call me at the number specified
below or call the AXA Customer Care Hotline at +632 85815-292.
EBBAH, NURTALEEB AMINULA

218525
57923
639260038310

PREMIUM DETAILS
Plan/Supplements Cover up Sum Insured / Annual Premium
to Age* Coverage (PHP) (PHP)
HEALTH START 20-PAY 100 1,000,000 14,730.00
Total Initial Annual Premium 14,730.00

Semi-Annual Premium 7,659.60
Quarterly Premium 3,977.10
Monthly Premium 1,399.35
*Cover up to Age refers to Termination Age.
Notes:
The premium rates for Health Start are not guaranteed and the Company reserves the right to review and adjust the premium
rates from time to time. We will communicate any change in premium rates by mail or in any other applicable form.
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.

ILLUSTRATION OF BENEFITS
Death Benefit /
End of Guaranteed Return of
Attained Age Total Living Benefit Major Critical
Year Cash Value Premium
Conditions Benefit
1 25 0 0 0 1,000,000
2 26 0 0 0 1,000,000
3 27 0 0 0 1,000,000
4 28 0 0 0 1,000,000
5 29 1,755 0 1,755 1,000,000
6 30 11,732 0 11,732 1,000,000
7 31 23,729 0 23,729 1,000,000
8 32 36,146 0 36,146 1,000,000
9 33 49,013 0 49,013 1,000,000
10 34 62,341 0 62,341 1,000,000
15 39 144,670 0 144,670 1,000,000
20 44 243,336 0 243,336 1,000,000
25 49 289,750 0 289,750 1,000,000
46 70 525,003 0 525,003 1,000,000
51 75 354,733 294,600 649,333 705,400
56 80 379,378 0 379,378 705,400
61 85 412,597 0 412,597 705,400
66 90 451,917 0 451,917 705,400
71 95 498,079 0 498,079 705,400
76 100 561,533 0 561,533 705,400
Notes:
1. The Guaranteed Cash Value refers to the amount paid to the Owner upon termination of the policy prior to death. Any Minor Critical
Conditions benefit claims paid are deductible from the Guaranteed Cash Value. At any time, the total Minor Critical Conditions benefit
paid is higher than the Guaranteed Cash Value, the surrender amount is reduced to zero.
2. The Return of Premium refers to the cash endowment paid on the Policy Anniversary nearest the 75th birthday of the insured. For issue
age up to 49, this is equivalent to 100% of total standard premiums paid. For issue age 50 and up, this is equivalent to 50% of total
standard premiums paid. Illustration assumes that there were no minor condition claims made or any outstanding loans.
3. The Total Living Benefit refers to the sum of the Guaranteed Cash Value, and the Return of Premium (if any) payable to the Owner if
he/she decides to surrender/terminate the plan. The Return of Premium is illustrated as paid out at age 75.
4. The Death Benefit or the Major Critical Conditions Benefit is (1) the sum insured payable upon the demise of the insured or diagnosed
of any of the covered Major Critical Conditions less (2) any Minor Critical Conditions Benefits paid, any cash endowment paid, and any
Indebtedness.
5. The Minor Critical Conditions Benefit can be claimed for a maximum of 4 times throughout the lifetime of the policy and should be for
different conditions, except for carcinoma-in-situ of different organs. The amount of benefit paid or payable will be deducted from the
Major Critical Conditions Benefit, Death Benefit, Guaranteed Cash Value or Return of Premium payable under the Basic Plan.
6. All amounts are in the currency indicated in the Summary of Benefits page.
7. This proposal is only an illustration of the key features, benefits and assumptions of the recommended insurance plan. For the
complete terms, conditions and limitations of the plan please refer to your policy contract.

CONDITIONS COVERED
Major Critical Conditions
Cancer
Heart Attack
Stroke
Terminal Illness
Minor Critical Conditions

Conditions related to Cancer 1. Carcinoma-in-situ at Breast, Uterus, Fallopian
Tube, Vagina, Cervix Uteri, Testicles, Ovary, Colon,
Rectum, Penis, Lung, Stomach or Vulva
2. Early stage prostate cancer
3. Early Bladder Cancer
4. Early Chronic Lymphocytic Leukemia
Conditions related to the Heart 5. Angioplasty and Other Invasive Treatments for
Coronary Artery Disease
6. Aortic Aneurysm
7. Insertion of Pacemaker or Defibrillator
8. Keyhole Coronary Bypass Surgery
Conditions related to the Nervous System 9. Cerebral shunt insertion
Critical Conditions under the Child Cover Benefit

1. Dengue Hemorrhagic Fever (Grades III and IV)
2. Hemophilia A or Hemophilia B
3. Insulin Dependent Diabetes Mellitus
4. Kawasaki Disease
5. Osteogenesis Imperfecta
6. Rheumatic Fever with Valvular Impairment
7. Still’s Disease
8. Wilson’s Disease
Notes :
1. Any child of the Insured may receive a Child Cover Benefit provided that the child is under eighteen (18) years old at the time of first
diagnosis of the covered Child Critical Condition. This benefit is payable once only, on a first child-to-claim basis.
2. The critical condition must occur 60 days after the policy’s effective date for the corresponding Major Critical Condition Benefit,
Minor Critical Condition Benefit or Child Cover Benefit to be payable. These benefits are payable according to the illness definitions as
set out in the policy contract.

MAJOR CRITICAL CONDITIONS

No. ILLNESS NAME DEFINITION
1. Cancer The first unequivocal diagnosis of any malignant tumor characterized by the
uncontrolled growth of malignant cells and invasion of tissue, and positively diagnosed
with histological confirmation by a specialist and/or by Our medical director or
authorized medical consultant. The term malignant tumor includes leukemia, sarcoma
and lymphoma except cutaneous lymphoma (lymphoma confined to the skin).
Breast carcinoma in situ with subsequent radical mastectomy and radiotherapy is

covered.
For the definition shown above, the following are excluded:

1. All tumors which are histologically classified as benign, carcinoma in situ, pre-
malignant, non-invasive, having borderline malignancy or having low
malignant potential;
2. Tumors treated by endoscopic procedures alone and urinary bladder tumors
that have not Invaded the muscle layer (Tis and Ta)
3. Tumors of the skin with the exception of malignant melanoma greater than
0.7 mm Breslow and/or histologically described by the AJCC seventh edition
TNM classification greater than stage T1aN0M0
4. All prostate tumors unless histologically classified as having a Gleason score
greater than 6 or having progressed to at least clinical TNM classification
T2N0M0
5. Thyroid tumor in its early stages that measures less than 2cm in diameter
and histologically described as T1N0M0 from TNM classification of the AJCC
Seventh Edition
6. Chronic lymphotic leukemia unless histologically classified as having
progressed to at least Binet Stage A
2. Heart Attack Death of heart muscle due to inadequate blood supply that has resulted in ALL of the
following evidence of acute myocardial infraction:
· New typical ischemic changes in the electrocardiograph:new ST-T changes or

new left bundle branch block or new pathological Q waves;
· The characteristic rise of cardiac biomarkers or Troponins recorded at the
following levels or higher:
Troponin T > 200ng/L (0.2 ng/ml or 0.2 ug/L)
AccuTnl > 500ng/L (0.5 ng/ml or 0.5 ug/L)
The following are excluded:
· Other acute coronary syndromes

· Angina without myocardial infraction

3. Stroke Stroke means the death of brain tissue caused by hemorrhage, embolism or
thrombosis resulting in permanent neurological deficit with persistent clinical
symptoms. There must be clear and obvious abnormalities of sensory or motor
functions during the physical examination performed by a neurologist and/or by Our
medical director or authorized medical consultant. The incident must be demonstrated
by Magnetic Resonance Imaging (MRI), Computerized Tomography (CT) or other
reliable imaging techniques approved by the Company.
The following are excluded:

· Transient ischemic attack
· Brain tissue damage caused by head injury
Death of tissue of the optic nerve or retina / eye stroke
4. Terminal Illness The life Insured must be suffering from a condition, which in the opinion of a specialist
and/or by Our medical director or authorized medical consultant, according to Our
guidelines, will lead to death within twelve (12) months.

MINOR CRITICAL CONDITIONS

1. Carcinoma-in-situ Carcinoma-in-situ is defined as a focal autonomous new group of carcinomatous cells
which has not yet resulted in the invasion of normal tissue. Invasion means an
infiltration and/or active destruction of normal tissue beyond the basement
membrane. Diagnosis of carcinoma-in-situ must be supported by a histopathological
report and a positive result of a microscopic examination of fixed tissue, and confirmed
by a biopsy result. Clinical diagnosis does not meet this standard.
For the purpose of this policy, carcinoma-in-situ is limited only to the following 13
organs:
(1) Cervix Uteri* (8) Colon
(2) Uterus (9) Lung
(3) Breast (10) Penis
(4) Vagina (11) Rectum
(5) Fallopian Tube (12) Stomach
(6) Ovary** (13) Vulva
(7) Testicles
*For carcinoma-in-situ of cervix uteri, it must be at a grading of not less than CIN III and
be positively diagnosed upon the basis of a microscopic examination of fixed tissue
from a cone biopsy or colposcopy with cervical biopsy.
**For carcinoma-in-situ of ovary, the tumors should be capsule intact, with no tumor
on the ovarian surface, classified as T1aN0M0, T1bN0M0 (TMN classification) or FIGO
1A, FIGO 1B (The Federation Internationale de Gynecologie et d’Obstetrique).
In order to qualify for a benefit under this illness for the second time, the Carcinoma-in-
situ of the second claim must be a Carcinoma-in-situ of the organs that is different
from the organ of the first claim for which benefit has been paid.
For the avoidance of doubt, for those organs with both left and right component
(including but not limited to breast, ear, eye, fallopian tube, kidney, lung, ovary and
testicle), the left component and right component of the organ shall be considered as
one and the same organ.
2. Early Stage Cancer of A prostate malignant tumor which is histologically classified as T1a, T1b, T1c according
Prostate to the TNM classification system or another equivalent classification, and having a
Gleason score below 7. The diagnosis must be based on histopathological features
and confirmed by a Specialist. Pre-malignant lesions and conditions, unless listed
above, are excluded.
3. Early Stage of Urinary/ Bladder cancer which is histologically described using TNM classification as T1N0M0
Bladder Cancer as well as Papillary micro-carcinoma of Bladder. Diagnosis must be supported by
histopathology report.
4. Early Stage of Chronic Chronic Lymphocytic Leukemia (CLL) RAI Stage 1 or 2. RAI stage CLL 0 or lower is
Lymphocytic Leukemia excluded.
5. Insertion of Pacemaker The undergoing of insertion of a permanent cardiac pacemaker or a cardiac
or Defibrillator defibrillator to correct serious cardiac arrhythmia which cannot be treated via other
methods. The insertion of the cardiac pacemaker or cardiac defibrillator must be
certified to be medically necessary by a specialist in cardiology and/or by Our medical
director or authorized medical consultant, according to Our guidelines.

6 Angioplasty and Other The actual undergoing of balloon angioplasty, atherectomy or laser treatment to
Invasive Treatments for correct narrowing in major coronary arteries (defined as being greater than 50%
Coronary Artery Disease stenosis in 2 or more major coronary arteries; or being greater than 75% stenosis in 1
or more major coronary artery by angiogram). The treatment must be considered
medically necessary by a specialist and/or by Our medical director or authorized
medical consultant, according to Our guidelines, either to relieve exercise limiting
symptomatology which is not responding adequately to medical therapy or in order to
achieve a prognostic benefit. For purposes of this definition, “major coronary artery”
refers to any of the left main stem artery, left anterior descending artery, circumflex
artery and right coronary artery (but not including their branches).
In order to qualify for a benefit under this illness, there must be:
(1) History of symptoms which are sufficiently severe to indicate that the Life Insured’s
future level of exercise tolerance would be restricted, despite medications, to a
minimal level without percutaneous intervention; and
(2) Medical evidence including all of the following:
2.1 Report from attending specialist; and
2.2 Evidence of significant and relevant ECG changes (ST segment depression of 2
millimeters or more); and
2.3 Angiographic evidence to confirm the location and degree of stenosis in major
coronary artery.
7. Aortic Aneurysm The diagnosis of a large abdominal or thoracic aortic aneurysm as evidenced by
appropriate imaging technique. The aorta must be enlarged greater than 50 mm in
diameter and the diagnosis must be confirmed by a specialist in cardiology and/or by
Our medical director or authorized medical consultant, according to Our guidelines. For
this definition, aorta means the thoracic and abdominal aorta but not its branches.
8. Keyhole Coronary The undergoing for the first time for the correction of the narrowing or blockage of one
Bypass Surgery or more coronary arteries with bypass grafts via "Keyhole" surgery. The surgery must be
considered medically necessary by a Specialist. All intra-arterial catheter-based
techniques are excluded from this benefit.
9 Cerebral Shunt Insertion The actual undergoing of surgical implantation of a shunt from the ventricles of the
brain to relieve raised pressure in the cerebrospinal fluid. The need of a shunt must be
certified to be medically necessary by a specialist in neurology.

CHILDREN COVER BENEFIT CRITICAL CONDITIONS

1. Dengue This severe grade of dengue is characterized by circulatory failure (Dengue Shock Syndrome
Haemorrhagic DSS - WHO DHF grades III and IV), in addition to the 3 symptoms below:
Fever (Grades
III and IV) 1) High fever;
2) Hemorrhagic phenomena;
3) Hepatomegaly.
The diagnosis of Dengue Hemorrhagic Fever must be confirmed by a specialist and/or by Our
medical director or authorized medical consultant, according to Our guidelines. Non-
Hemorrhagic Dengue Fever is excluded.
2. Hemophilia A The covered child or children must be suffering from severe hemophilia A (VIII deficiency) or
OR Hemophilia hemophilia B (IX deficiency) with factor VIII or factor IX activity levels less than one percent (1%).
B Diagnosis must be confirmed by a specialist and/or by Our medical director or authorized
medical consultant, according to Our guidelines.
3. Insulin Diabetes mellitus is chronic hyperglycemia, caused by defective insulin secretion. Insulin
Dependent Dependent Diabetes Mellitus is characterized by the continuous dependence on exogenous
Diabetes insulin for the preservation of life as diagnosed by a specialist and/or by Our medical director or
Mellitus authorized medical consultant, according to Our guidelines, and such dependence must persist
for at least 180 days.
4. Kawasaki This is acute, febrile and multisystem disease of children, characterized by non-suppurative
Disease with cervical lymphadenopathy, skin and mucous membrane lesions. Diagnosis must be confirmed
Heart by a specialist and/or by Our medical director or authorized medical consultant, according to
Complication Our guidelines, and there must be echocardiograph evidence or any other imaging test showing
cardiac involvement manifested by dilatation or aneurysm formation in the coronary arteries
which persists for at least 180 days after the initial acute episode.
5. Osteogenesis This is a genetic disorder characterized by brittle, osteoporotic, easily fractured bones. The
Imperfecta covered child or children must be diagnosed as a type III Osteogenesis Imperfecta confirmed by
the occurrence of all of the following conditions:
1) The result of physical examination of the covered child or children by a Doctor that the
covered child or children suffers from growth retardation and hearing impairment; and
2) The result of X-ray studies reveals multiple fracture of bones and progressive
kyphoscoliosis; and
3) Positive result of skin biopsy.
Diagnosis of Osteogenesis Imperfecta must be confirmed by specialist and/or by Our medical

6. Rheumatic A confirmed diagnosis by a specialist and/or by Our medical director or authorized medical
Fever with consultant, according to Our guidelines, of acute rheumatic fever according to the revised Jones
Valvular criteria for its diagnosis. We only cover the case where there is involvement of one or more
Impairment heart valves and at least mild valve incompetence or stenosis attributable to rheumatic fever as
confirmed by quantitative investigations of the valve function by a qualified cardiologist
acceptable to Us.

7. Still's Disease The occurrence of Still's Disease, a form of Juvenile Idiopathic Arthritis (JIL), where all
of the following conditions are met:
1)
There is widespread joint destruction as a result of the disease necessitating
hip or knee replacement; and
2) The diagnosis has been confirmed by a specialist and/or by Our medical
8. Wilson's Disease A potentially fatal disorder of copper toxicity characterized by progressive liver disease
and/or neurologic deterioration due to copper deposit. The diagnosis must be
confirmed by a specialist and/or by Our medical director or authorized medical
consultant, according to Our guidelines, with liver biopsy and the treatment with a
chelating agent must be documented for at least 180 days.
Notes:
1. We will not pay the Major Critical Condition, Minor Critical Condition or the Child Cover Benefit under any of the
following:
a. The Insured is suffering from any Major or Minor Critical Conditions within sixty (60) days following the
Policy Effective Date or last reinstatement date of this Policy, whichever is later
b. For illnesses relating to congenital abnormalities
c. Any act of War (whether declared or not), invasion or acts of foreign enemies, civil war, revolution, rebellion,
civil commotion assuming the proportions of, or amounting to, an uprising against the government, riot or
insurrection, strike, or terrorist acts
d. Nuclear, biological or chemical (NBC) contamination
e. Any self-inflicted injury or suicide or any attempt thereat, whether sane or insane
f. Any unprescribed drug or alcohol abuse
g. Under Child Cover Benefit, we will not pay if the child is suffering from any covered child conditions within
sixty (60) days following the Policy Effective Date or last reinstatement date of this Policy, whichever is later
or the Child Critical Condition which resulted to death is within fourteen days from its diagnosis.
h. Pre-existing conditions as defined is permanently excluded
In case of Child Critical Condition Benefits, illnesses relating to congenital abnormalities are payable.
2. Pre-existing condition means a condition for which the Insured received medical advice, consultation or treatment,
or whose signs or symptoms are evident, or should have been evident to the Insured, even if the Insured did not
seek medical advice, consultation or treatment for it prior to the Effective date of this Policy or date of effectivity of
its last reinstatement, if any. “Condition” means any type of illness, specific injury, disease or infirmity including all
underlying or related conditions and any manifestation thereof, whether in one (1) or more than one body system.
3. Cooling-off Period: You may return or cancel the contract within 15 days from the date you receive the contract. The
amount paid shall be returned in full to you.

DECLARATIONS AND ACKNOWLEDGEMENTS

Declarations
I confirm having read and understood the information contained in the Illustration of Benefits Page. My Financial
Advisor/Financial Executive fully explained to me the benefits, feature and, exclusions and limitations related to this
product. I understand that certain conditions may not be payable under the plan, as illustrated in the Exclusions and
Limitations of this proposal and detailed in the Exclusions and Limitations section of the policy contract. I
understand that the illustration(s) given to me are provided only to show how policy benefits would change over time
under a specific set of assumptions. In case of conflict between this Sales Illustration and the issued policy, the
latter shall prevail.
CONFORME: These declarations and acknowledgements are made with the
knowledge of AXA representative whose signature appears below:
Applicant/Policy Owner Date Financial Advisor/Financial Executive Date

Signature over Printed Name Signature over Printed Name
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, and 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. Please carefully read the
policy and endorsements and consider the risks, charges and expenses before buying the policy. You
should seek professional advice from your financial, tax, accounting or legal consultant before buying the
policy.
THIS FINANCIAL PRODUCT OF AXA PHILIPPINES IS NOT INSURED BY THE
PHILIPPINE DEPOSIT INSURANCE CORPORATION (PDIC) AND IS NOT
GUARANTEED BY METROBANK OR PS BANK.

Reference Number: 57923-202302020848-2-02
FINANCIAL UNDERSTANDING SUMMARY
Dear ALFHADZRY,
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 18,000.00, and after taking into consideration your objectives, risk
profile and priorities, you have selected Health Start 20-Pay for your Health need.
The details of your insurance coverage and your insurance premium are summarized in your
Health Start 20-Pay sales illustration.
EBBAH, NURTALEEB AMINULA

218525
57923
639260038310
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.

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Health Start Proposed Insured:

Mr. ALFHADZRY BOLIVAR JUMLI

Page 1 of 13 of Proposal No. 57923-202302020848-2-02

EBBAH, NURTALEEB AMINULA

Page 2 of 13 of Proposal No. 57923-202302020848-2-02

Total Initial Annual Premium 14,730.00

*Cover up to Age refers to Termination Age.

Page 3 of 13 of Proposal No. 57923-202302020848-2-02

Page 4 of 13 of Proposal No. 57923-202302020848-2-02

Minor Critical Conditions

Critical Conditions under the Child Cover Benefit

Page 5 of 13 of Proposal No. 57923-202302020848-2-02

MAJOR CRITICAL CONDITIONS

Breast carcinoma in situ with subsequent radical mastectomy and radiotherapy is

For the definition shown above, the following are excluded:

· New typical ischemic changes in the electrocardiograph:new ST-T changes or

The following are excluded:

· Other acute coronary syndromes

Page 6 of 13 of Proposal No. 57923-202302020848-2-02

The following are excluded:

Page 7 of 13 of Proposal No. 57923-202302020848-2-02

MINOR CRITICAL CONDITIONS

Page 8 of 13 of Proposal No. 57923-202302020848-2-02

Page 9 of 13 of Proposal No. 57923-202302020848-2-02

CHILDREN COVER BENEFIT CRITICAL CONDITIONS

Diagnosis of Osteogenesis Imperfecta must be confirmed by specialist and/or by Our medical

Page 10 of 13 of Proposal No. 57923-202302020848-2-02

Page 11 of 13 of Proposal No. 57923-202302020848-2-02

DECLARATIONS AND ACKNOWLEDGEMENTS

Applicant/Policy Owner Date Financial Advisor/Financial Executive Date

Page 12 of 13 of Proposal No. 57923-202302020848-2-02

FINANCIAL UNDERSTANDING SUMMARY

EBBAH, NURTALEEB AMINULA

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