C C LIFE TYPE OF LOAN 1. Ne$iL@n 2. Additiond P 3. Renelflal I)etalle of prorlous loans, Additlonal ard R€nqvd con$endyfllled out. (Cl banr should be induded) thotrld be AyalaAvenueMakatiCity1226 Building,6807 COCOLIFE MCCP.O.Box 1681.Tel.No.(632)812'9015FaxNo.812-9053.W6bsite:www.cocolife.com a 3 4. 5 ' For additimal list oap€vbus banq kltxtly u96 th3 bck page ot lh€ aFpllcation iotm b bs}qrd tlp no{nedicel linil thc prE||lum I{OTE: lf the total bil amut paymnts are only consideed ss pFrium dep6|t. Ths clbnt shrll h(b|go mdbal qaminatbn it his/tFr total $m a$ur€d excaeds th€ n6{rcdi:l lirit. APPLICATIOI{FORCREDITLIFE INSURANCECOVERAGE (r{arE oF PoIJCYHoLDERTREDITOR} GROUPPOLTCY NO._ APPLN. NO. GMDCLIOg3 52 3 42 PERSOT{ALDATA FIRST NAME: LqST MIDOLE ADDRESS TESIDENCE )ATE OF BIRTH {EIGHT }IVILSTATUS IPIACE OF BIRTH IWEIGHT TELEPHONE NUMBER SEX JSS& GSIS TIN sCCUPATION IATURE OFWORK F SEAMAN,PORTOF ENTRY F OCW / OFW, DESTINATION COUNTRT II. BETEFICIARY'IES It is understoodthat the beneficiary/iesshare equally and are designatedas RevocaHe unless otherwise indicated in the 'REMARKS' NAME AGE RELATIONSHIP REMARKS OCCUPATION & R&..ry"rHJ CITASTAC.FT,,A]\jT N{II'CTTIS I CC},FAI.II.1:S r.'IT;nT-i,lr-)F0-59 Cnnom,{TT\rE HEALTH DECLARATION I hereby wanant and dedare lo the best of my knorledge that on the date of tfE releaseof my loan, I am cunenuy well and possesssound health and am aHe to performthe usual activitiesin the pursut of my livdihood, anclthat: 1. I am in good health and entirdy free from any mental or physicalimpairmentsor deformities. 2. I have not suffered or do now suffer trqn: a) dlsease of the circulatfy system (e.9. heart trouble, rheumatlcfer/er,hilghblood pressure,dlsease.of the arteries and veins); b) disease of the resFiratqy system (e.9. tuberculosis,asthma, persistent ccugh, pneumonia);c) .diseageof the genito.urinary system (e.9. infedions of the kidneys.urinary or genilal organs.renal stones. ilenerealdisease);d) disease of tte gastro-iril'estinal system (e-9. digestive disorders,gasfic or duodeinalulcer, hepatitisB or other disordersof the liver, disordersof the gall Uadder);e) diseasesof the nervoussystem or mental disorders (e.9. eftlepsy, fits o fainting attacks, fequent headafies, nervbus.breakdo,vn);0 diabdes, canoer, or arry disease of the blood, glands, spleen, ears, eyes, or skin; g) unexdained night sweat and or/loss of weight, persistentfever, chronic or recurGnt diarrhea, unexplainedinfections, swollen glards; h) any other diseasesor ailmentsnot mentionedabove. 3. I never had q been advisedto have hosrital trealmentor swgery. 4. I never had or been advisedto have a bloodtest for AIDS or an AlD$rdated conditiontr have ever been refused 6 a blood donor5. I have not consrlted a physicianfor any reason,includingrouline examinationsand dood tests, or hane receivbdblood transftrsionswithin the past five (5) years. 6. I have not receivedr now recdve disatility bernfit. 7. ,l have not appliedfor insurancewhich was declined,postponedor modiftedin dan or rate for anylife or disabilitylrBurance. EXCEPTIOI{STO THE ABOVE The fdregoingstatement and answers,arefull, completeand true. I agreethat they shall be the basis of the issuanceof insurancefer me under the Grorp Policy ard the COCPL.ILEshall nqt be liade fr any claim on account of illness, injury, or death, the cause of which was known pior tg approval of my recgest for insuranceand withhdd or concealedinthe above $atements. ' In as much as I cannot read, write, or urderstand the language, before I afiix my thumbmarks (duly witnessed) to this application,it has been read and translaiedto me by the Creditor'sadhorized officer or representative. IV. AUTHORIZANONTO FURNISHIf,EDICAUOTHERRE-LATEDINFORMATION |herebyauthorizeanyphy;ician,medica|practitioner/provider,dirdc,hospita|,orottEfmedica||y.re|atedfaci|ity,ir6wanGe-company,govemmentofprivateo@ or other person, organization,or insUtutionthat has dny record or knowledge of my Medical/HealthHistory and any information relded theretq to give to COCOLIFEor its HO Undelwdter,Medical Directoi,onany named-rerlresentative, any such information/records. This'information'pertdns to all records containing medical or non-medicaldata induding, but not limited tq mental and dental Care, drug or dcohol trse, prescribeddrugs, informationabout communicablediseaseswhich include, but nd limitedto, human immunodeficiencyvirus (HlV), acquiredimmunodeficiency syndrome(AIDS) and AIDS rdated comdex (ARC), and any emfloymgnt and insurancecovefage infcrnta$onAso, I hereby authoize Q@lf! to obtain an investigativereportfrom a duly aulhorizedinspectionagencywhich wilfprovide any appticableinformationconcerningmy charac{er,generalreputation,personal characterigics, mode of living, health and financial status tfrough interviewswith friends, neighbors,and associates; and to obtain and make a briCf repod regardingmy insurat*lityto the MedicalInformaUonBureau (MlB),which operatesas.an inform'ationexchangewith other Life Insuance Cgmparies. This authorizationis in connectionwith my applicationfor insuran@andor any insurancedaim that may arise therefrom. Signed at this day of 20_. THUMBMARK Witnessedandissued!y: Credit./s'Arthortred officer Signaturoof ,Applicant 'ln €se GMD-074-0309-1 ol lhteEto AFI€rt