CREDIT LIFE INSURANCE

CONFIRMATION FORM
Date
Please be informed of the details of your Credit Life Insurance for your <type of loan>
Fill out details and out "N/A" if not applicable. Print legibly using BLANK INK.
Name of Assured ( Last, First and Middle Name)

Birthday (Month, Day, Year )

Age

Gender

Home Address (Unit/ Floor/ Level/ Building Name, Number, Street, Baranggay

Municipality/ City/Province

Zip Code

Country

Nationality

Contact Numbers (Please provide atleast two)

Home Phone Number
Mobile Number

Business Phone Number

Email Address

Company Name

Occupation

Place of Work

Loan Amount

Nature of Business

Loan Term

Premium Amount

Agreement by the Borrower

a. I am fully aware of and voluntary agree to the following eligibility requirements for the insurance cover, and understand that my insurance
claim may be denied should I fail to possess any of the following eligibility requirements:
i.
I am at least 18 years of age but have not attained the age of 71, Filipino citizen
or resident, with address in the Philippines.
ii.
I am able to perform all of the activities of daily living without the assistance
from another person, as follows: bathe or shower, dress or undress, use a toilet, get in and
out of bed or chair, walk on a level surface, eat and drink, and control bowel and bladder
iii.
I have not been hospitalized as an in-patient for 3 consecutive nights at any
time during the last 12 months due to heart illness, cancer, or stroke.
b. I understand that I shall be automatically be insured under Credit Life Insurance without the need of medical examination, provided I am
eligible for coverage and the total loan obligation to the Creditor does not exceed the No Medical Limit of the accredited insurance provider.
c. I consent to the Creditor using my personal information to evaluate and assess my application for loan or need for Credit Life Insurance
coverage, as well as to service any of my accounts or insurance coverage, including the evaluation of any future claims. I also authorize the
Creditor to disclose my personal information to any of its affiliated entities or to persons or entities providing services on the Creditors behalf
d. Unless prohibited by law, I hereby authorize any physician, hospital, clinic, insurance company, or other organization, institution or person
that has any records or knowledge of my health to disclose to AXA Philippines or its representatives any and all information with reference to my
health and medical history or hospitalization, medical advice, treatment, disease, and ailment. A photocopy of this authorization shall be effective
and valid as original.
e. I fully authorize the Creditor to furnish the insurance provider and to other entities that may have direct or indirect interest to the loan or for
regulatory or any other examination on the part of the Creditor, all the details contained in this document.
f. I declare that the above answers are true and correct to the best of my knowledge and that I have not withheld any relevant information
which might have otherwise affected the acceptance of my proposal. I understand and agree that the insurance applied for will become effective
only upon acceptance by the Company and the premium being fully paid by me.
g. By filling out this form, providing my personal information, and affixing my signature herein I give full and unconditional consent and waive
my rights under the Republic Act 10173 also known as the Data Privacy Act of 2012 and other relevant laws.
h. Any material falsity or misrepresentation in the foregoing shall entitle AXA Philippines to declare the insurance null and void from the
beginning, while the same has not been in force for more than 1 year from the effective date, during the life of the insured.

Signed at _________________ this____day of_________,_____.

Place
Day
Month Year
_________________________________________________
Signature of Borrower