APPLICATION FORM

FULL MEDICAL UNDERWRITING

MyHEALTH

INDIVIDUAL

MEDICAL PLANS

www.april-international.com

Please print only if necessary

THIS IS YOUR APPLICATION FORM. COMPLETE IT, SIGN IT, SEND IT.

WANT TO SAVE TIME?

THE SUBMIT BUTTON AT THE END OF THIS FORM ALLOWS YOU TO SEND A SOFT COPY TO

US IMMEDIATELY.

WE WILL ARRANGE FOR THE SIGNING OF THE FORM AT A LATER STAGE

AN UNDERWRITING OFFER WILL BE PROVIDED IN 2 WORKING DAYS OR LESS.

IF YOUR APPLICATION HAS BEEN ACCEPTED, IN 5 WORKING DAYS, YOU WILL RECEIVE:

• By Email: Your policy documents to the email address provided in your application.

• By Post: Your personalised member card

IF YOU WOULD LIKE TO HAVE YOUR POLICY DOCUMENTS IN A PRINTED

FORMAT AND POSTED TO YOU, PLEASE MAKE YOUR REQUEST ON PAGE 1 OF

THE APPLICATION FORM.

Y O U R A P P L I C AT I O N , S T E P B Y S T E P.

IMPORTANT NOTICE:

The answers you give to the questions contained in this Application will form the basis of any insurance policy issued, and will be incorporated into the contract. It is essential that you give accurate, truthful, and complete information for all persons to be insured, as inaccuracies may jeopardise coverage or invalidate a claim.

Postal Code: Country: If you wish to use a different mailing address please advise us

Gender: Height (cm): Weight (kg):

Marital Status:

ID/ Passport No.:

Mobile:

FAMILY MEMBERS TO BE INSURED

Family Member 1 Family Member 2 Family Member 3 Family Member 4

Family Name

First Name(s)

Date of Birth

Gender

Marital Status

Relationship to Applicant

Nationality

Smoker

ID/Passport No.

Occupation(specify nature of duties)

Height and Weight

APPLICANT’S DETAILS

Family Name:

First Name(s):

Date of Birth:

Occupation:

Smoker:

Nationality:

Residential Address*:

Tel.:

Email:

* This policy is only available to applicants whose usual country of residence is the Philippines.

CORE OPTIONS APPLICANTFAMILY MEMBER

1 2 3 4

Hospital and Surgery

Annual Deductible

Your selected deductible applies to the Hospital and Surgery module only.

Area of Cover

The area of cover chosen will apply to all modules selected. Services rendered outside of the area of cover are covered up to US$50,000 per period of insurance, only if they are directly caused by sudden illness or injury occurring during the first 30 travel days of any trip outside of your area of cover. Please refer to Clause 4 of the Policy Terms and Conditions.

OPTIONAL MODULES APPLICANTFAMILY MEMBER

1 2 3 4

Outpatient

Dental and/or Optical

Optical included with Elite plan only

Maternity

Important: Available to women between 19 to 45 years of age who have selected at minimum an Extensive or Elite Hospital and Surgery on a NIL deductible basis, plus an optional Outpatient module.

Essential $100,000Essential $500,000ExtensiveElite

Essential $100,000Essential $500,000ExtensiveElite

Essential $100,000Essential $500,000ExtensiveElite

Essential $100,000Essential $500,000ExtensiveElite

Essential $100,000Essential $500,000ExtensiveElite

WorldwideWorldwide excluding USAASEAN excluding Singapore

WorldwideWorldwide excluding USAASEAN excluding Singapore

WorldwideWorldwide excluding USAASEAN excluding Singapore

WorldwideWorldwide excluding USAASEAN excluding Singapore

WorldwideWorldwide excluding USAASEAN excluding Singapore

Nil$500$1,000$2,500$5,000$10,000

Nil$500$1,000$2,500$5,000$10,000

Nil$500$1,000$2,500$5,000$10,000

Nil$500$1,000$2,500$5,000$10,000

Nil$500$1,000$2,500$5,000$10,000

INSURANCE DETAILS

Have you or any person to be insured ever applied for, been covered under, or held a policy administered by APRIL International (formerly GlobalHealth)? If Yes, please give details.

Do you or any person to be insured currently have health insurance with another company? If Yes, please give details and indicate if it will be continued (and if not, as of what date).

Have you or any person to be insured ever had a policy or application for life, sickness, accident disability, critical illness or medical insurance refused or cancelled, or had any special terms imposed? If Yes, please give details.

MEDICAL DETAILS AND HISTORY

Please indicate if you or any person to be insured have or have ever had any of the signs, symptoms, illnesses or disorders below by ticking the appropriate box.

1 Cancer, leukaemia, tumour or neoplasm (including benign growths), cysts including fibrocystic breast disorder, or any blood disorder

2 Asthma, chronic bronchitis, allergies, chronic rhinitis or sinusitis, tuberculosis, any disease or disorder of the lungs

3 Chest pain, raised blood pressure, heart condition, circulatory disorder

4 Indigestion, gastric reflux, gastric ulcer, haemorrhoids

5 Spinal condition, bone fracture, joint injury, back, neck or muscle pain

6 Malaria, dengue fever, other tropical illness

7 HIV/AIDS

8 Kidney Stones, kidney disorder, disorder of the urinary bladder or tract

9 Diabetes, liver disorder, hepatitis

10 Disorder of the brain or nervous system, stroke, aneurysm

11 Mental health problem, anxiety, addiction

12 Gynaecological disorders including pregnancy, irregular periods or bleeding, menstrual pain, complicated pregnancy, HPV infection, or an abnormal smear test result

13 Eczema, dermatitis, disorder of eyes, ears

14 Congenital conditions

15 Any other disorder/injury

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Person to be insured Question no.

Date of first consultation

Details of Medical condition, including nature of

treatment, results, date of last consultation,and whether you have fully

recovered

Name & Address of doctor, Hospital or health professional

consulted

Do you requireany follow uptreatment or

consultation, ifso when?

16

Except as disclosed elsewhere in this form, have you or any person to be insured ever been admitted to hospital as an inpatient, or (within the last five years) undergone any procedures, scans, or diagnostic tests whether as an inpatient or outpatient? If Yes, please give details.

17

Are you or any person to be insured under medication? If Yes, please state the medicine name, dosage and the approximate cost.

18

Please enter the following details about the usual/family doctor for each person to be insured. If you do not have a usual/family doctor, please provide the names, addresses and contact information of medical providers you and your family members to be insured have seen in the last 3 years. Use a separate sheet if necessary. If you have never seen a doctor in the past 3 years, please indicate that below.

Name:

Address:

Telephone:

Email:

ADDITIONAL SPACE FOR FURTHER REMARKS

You may use this space for any further comments about any medical conditions you have or have suffered from. Please remember to enclose any supporting documents with your application.

COMMENCEMENT DATE

Preferred Commencement Date:

(Please note that the plan will not commence until premium has been received by the insurer)

INTERMEDIARY ACCESS

Would you like your insurance intermediary to have access to your policy details and claims transactions through their Online Portal?

Do you authorise us to discuss and/or share claims and medical information with your insurance intermediary?

Intermediary Name:

Company Name:

Telephone:

CLAIM REIMBURSEMENT

For international transfers to a foreign bank, note that your bank may charge you fees for each transaction which will be your responsibility to bear.

A/C No.:

Please provide your banking details for claim reimbursement.

Bank Name:

Bank Address:

A/C Name:

Currency: USD PHP

I/we hereby apply for a policy to be issued based on the statements contained herein and declare that all answers to the foregoing questions arecorrectly recorded, and that they are full, complete and true. I/We agree to disclose to the Insurer and its medical advisers all material facts andmatters of which I/we are aware and execute any document to empower the Insurer to obtain relevant information from any doctor, hospital, or othersource. Except as declared herein, all persons to be insured are currently in good health. I/We agree that if the health status of the above intendedinsured person changes after this application is signed and before the Insurer issues a policy I/We shall immediately notify the Insurer of the change.I/we agree that the policy as issued including all schedules, endorsements, and this application shall form the whole contract and that no insuranceshall be in force until and unless the application has been accepted, and the appropriate premium paid.

DATA PRIVACY: It is hereby declared that as a condition precedent to the liability of the Insurer, the Insured Individual(s) has agreed that any personal information collected or held by the Insurer is provided and may held, used and disclosed by the Insurer to individuals/organizations associated with the Insurer or any selected third party (within or outside the Philippines) for the purpose of processing the application and providing subsequent services for this and other financial products and services, direct marketing, data matching, and to communicate with the Insured Individual(s) for such purposes. The Insured Individual(s) has the right to obtain access to and to request correction of any personal information held by the Insurer concerning the Insured Individual(s). Such request can be made to QBE Seaboard Insurance Philippines, Inc.

NOTE: Under Republic Act 9160 (Anti-Money Laundering Act) as amended by Republic Act 9194 and pertinent regulations, all insurance companies are required to satisfactorily establish the identities of all its customers. Hence, QBE Seaboard Insurance Philippines, Inc. reserves the right to not accept and process any application for insurance if the customer fails to provide sufficient evidence to establish his identity.

Arranged and administered by:

APRIL Hong Kong Limited9th Floor, Chinachem Hollywood

1-13 Hollywood Road, CentralHong Kong

Phone: (+852) 2523 8778 | Fax: (+852) 2526 0769 Email: contact.ph@april.com

MH

PH 2

018/03

III

Underwritten by:

QBE Seaboard Insurance Philippines, Inc. 16th Floor BDO Equitable Tower 8751 Paseo de Roxas Makati City, 1226 Philippines Phone: (+632) 224 4040 | Fax: (+632) 224 4044

Cheque or Bank Draft – Annual Payment Only (US$)Cheques should be drawn on a Philippines clearing bank and made payable to “QBE Seaboard Insurance Philippines, Inc.”. Kindly provide the (1) Name of Applicant or policyholder; (2) Contact No.; (3) Name of Product; (4) Producer Code; and (5) Policy Number in a separate sheet.

Bank Transfer – Annual Payment OnlyFor direct premium remittances, please send full payment (inclusive of all bank charges) to:

Account Name: QBE SEABOARD INSURANCE PHILIPPINES, INC.Bank Name: CITIBANK, N.A.Bank Address: 2F Citibank Tower8741 Paseo de Roxas, Makati City 1200PhilippinesAccount No.: 5/602648/003 (USD)Swift Address: CITI PH MX

Notes1. All bank charges (outbound and inbound) will be borne by the remitter2. Please indicate your Policy Number as payment details to your bank3. Please email the bank remittance advice or instructions slip with your Policy Number to ops.ph@april.com for our

accounting records and to issue an Official Receipt

PERSONAL DATA PROTECTIONI/We give consent to QBE Seaboard Insurance Philippines, Inc. (“QBE”) and its employees, related companies, agents and service providers to collect, use and disclose all personal data for one or more of the purposes described in QBE’s Data Protection Policy, including but not limited to premium payment, collection, accounting, audit, compliance, regulatory, research, analysis, verification, and dispute resolution. I/We have read and agreed to the terms of the full Policy at http://www.qbe.com.ph/privacy-policy.html. If any personal data furnished is not about me/us, I/we warrant that I/we have obtained consent from the data subject (or if lacking in legal capacity, his/her legal representatives, guardians or parents as the case may be) for QBE to collect, use and disclose his/her personal data for the above purposes and on the terms in this document, and as if the said data are about me/us. I/We warrant that all personal data I/we have provided are accurate and complete, and I/we will inform QBE of any changes to the data as soon as practicable.

Signature of Cardholder

Notes: The liability of the Company (QBE Seaboard Insurance Philippines, Inc.) commences only when the proposal/renewal has been accepted by the Company and premium successfully deducted. Acceptance of premium does not constitute acceptance of liability.

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PREMIUM PAYMENT FORM

Alternatively, save this file and send it to contact.ph@april.com

Send the scanned copy to contact.ph@april.com

Mail to QBE Seaboard Insurance Philippines, Inc.

Attn: APRIL International16th Floor BDO Equitable Tower,

8751 Paseo de Roxas,Makati City, 1226 Philippines