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Friends Provident Global Term Singapore Expat Life Insurance

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					    A guide to completing the
  Global Term application form.



                                                          Application Form



                                                             Global Term




             Global Term can only be sold by authorised
                    Singapore Financial Advisers.




For use by authorised
Singapore Financial Advisers only
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM

    WARNING: PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT OF SINGAPORE (CAP.142), YOU ARE TO DISCLOSE IN THIS
    APPLICATION FORM, FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE THE
    POLICY ISSUED HEREUNDER, MAY BE VOID.

If	you	have	already	applied	for	cover	with	us,	please	state	your	policy	number	if	known.

Part 1 – Introduction                – It is most important that you read this Part before completing the Application form.

This Application form should be read in conjunction with the following documents, which set out the terms and conditions of the contract:
•	 The	Global	Term	product	summary	                       •		 The	Global	Term	policy	conditions	             •		 Your	Guide	to	Health	Insurance
•		 Your	personal	benefit	illustration	                   •		 Your	Guide	to	Life	Insurance
Please	complete	this	form	in	black	ink.	If	you	make	any	mistakes	while	completing	this	application	form,	please	cross	out	the	error	and	write	the	
new information clearly. The life assured must initial any corrections for questions they have answered. Do not use correction fluid or other ways
of deleting incorrect information.
Replacement of Life Policies                                              First (or only) Life                 Second Life
a) Does the life to be assured have any life insurance policy(ies)?
   If	‘Yes’,	please	complete	the	following	table                            Yes   3          No                  Yes            No
First (or only) Life
            Name of Company                   Country	of	Insurance      Type of policy    Sum Assured    Year	issued           Term
    AN INSURANCE COMPANY                   SINGAPORE                    WHOLE OF LIFE    SGD600,000            2007             N/A


                                                                                                                        List	details	of	any	existing	life	
                                                                                                                           insurance policies here.
Second Life

            Name of Company                   Country	of	Insurance      Type of policy    Sum Assured    Year	issued           Term




                                   First (or only) Life                                  Second Life
b)	 Is	this	application	
    intended to replace any
                                     Yes             No   3                                  Yes        No
    policies with this or any                                                                                                Only	tick	Yes	if	replacing	
    other life office?                                                                                                          an	existing	policy.
	    If	‘Yes’,	which	policies?

Warning:	It	is	usually	disadvantageous	to	replace	an	existing	life	insurance	policy	with	a	new	one.	Some	of	the	disadvantages	are:	
	 (i)	 You	may	not	be	insurable	on	standard	terms
	 (ii)	 You	may	have	to	pay	a	higher	premium	in	view	of	a	higher	age
  (iii) This may result in losing the financial benefits accumulated over the years.
In	your	own	interest,	we	would	advise	that	you	consult	your	present	insurer	before	making	a	financial	decision.	Then	you	can	make	a	
careful comparison.
Global	Term	is	underwritten	by	Friends	Provident	International	Limited	(Singapore	Branch).	Each	policy	will	be	entered	in	the	register	of	
Singapore policies.

1 Disclosure of all relevant information
	    •	 Help us to assess your application by giving us all the information we ask for. All the questions we ask are relevant and
        important. You must answer them accurately and completely to the best of your knowledge. If you do not, we will have the
        legal right to cancel any policy issued as a result of your application and to not pay any claim.
     •	 IF ANYTHING ABOUT YOUR HEALTH OR CIRCUMSTANCES CHANGES AFTER YOU HAVE COMPLETED THIS APPLICATION
        AND BEFORE WE ASSUME RISK FOR THE COVER APPLIED FOR YOU MUST LET US KNOW IMMEDIATELY. We need to know of
        any changes which would have resulted in different replies to questions asked either: on or resulting from the Application form or other
        questionnaire; or by any doctor or nurse acting on our behalf. To inform us of any such change, please telephone our Singapore office
        on +(00)65 6327 4019; e-mail: singapore.enquiries@fpiom.com
	    	 Changes	would	include	having,	or	expecting	to	have,	doctor,	hospital	or	clinic	consultations,	treatment	as	an	in-patient	or	out-patient	
        or a blood test for any reason. We also need to know immediately if you change your occupation, country of residence or intended
        residence, or take up any hazardous sports or pastimes before cover starts.
	    •	 If	we	are	advised	of	any	changes	we	will	confirm	in	writing	whether	or	not	any	terms	quoted	will	still	apply.
2 Terms and conditions
	    •	 You	should	seek	guidance	from	your	usual	Financial	Adviser	as	to	the	suitability	of	the	policy	to	your	own	particular	circumstances.
	    •	 Before	completing	this	Application	you	should	read	our	standard	terms	and	conditions.	You	are	entitled	to	ask	for	a	copy	of	your	
        Application form at any time.
3 Medical evidence
     FRIENDS PROVIDENT INTERNATIONAL LIMITED (SINGAPORE BRANCH) WILL ONLY PAY FOR MEDICAL INFORMATION WHICH
     IT HAS SPECIFICALLY REQUESTED.




XSG4/AP 07.11                                                                                                                                     Page 2
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Details of Financial Adviser                   To be completed by the Adviser
Financial Adviser Company
name and address                           ABC INSURANCE BROKER
(or stamp)                                 OFFICE ADDRESS
                                           SINGPORE                                      It	is	important	to	provide	us	with	a	valid	email	address,	so	
                                                                                          we	can	keep	you	updated	on	the	application’s	progress.
E-Mail	Address                            admin@abc.com.sg

FPI	agency	number                          7     9       1                                       Please indicate the type of fact-find carried out
                                                                                                 during the sale of this product by ticking the
                                          Telephone                                              appropriate	box:

                                          Fax	                                                         No advice

Country where advice is given             SINGAPORE                                                    Product advice only
                                                                                                                                  One	of	these	boxes	
Country where Application is signed       SINGAPORE                                                    Partial fact-find           must be ticked.

                                                                                                       Full fact-find


Please complete all sections
Failure to provide all relevant information and documentation will result in a delay to the proposal being processed. Further information may be
required during the validation process (i.e. questions arising from the information provided).

Please note that even if the premium has been received and banked, the policy will not be issued until all documentation has been
received and validated




                                  Checklist (please tick boxes)

                                     3      Part 2 – 9       :   Fully completed

                                     3      Part 12          :   Declarations signed

                                     3      Part 13          :   Method	of	payment	details	completed

                                     3      Enclosed	certified	copies	of	client	identity

                                      3     Enclosed	certified	copies	of	client’s	utility	bill	
                                            (or suitable alternative) to verify residential address
                                            Enclosed	certified	copy	of	client	visa	detailing	right	
                                      3     of residency e.g. employment pass OR Singapore
                                            permanent resident card




XSG4/AP 07.11                                                                                                                                   Page 3
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 2 – Personal details of life/lives to be assured
The Life (Lives) Assured is/are the person(s) on whose life (lives) the Policy will be written. Please complete in block capitals.
                                       First (or only) Life                               Second Life
	 1	Title	eg	Mr,	Mrs,	Dr,	Miss             Mr

                                            Male             3           Female                    Male                Female

    2 Surname                              TAN

    3 First name(s)                        JAMES
    4 Current residential address
                                           28 MAIN ROAD
      (including street name, town
      and area code if known)              05 - 39 THE BUILDING
                                           258374
                                           SINGAPORE
    5 Correspondence address
      (if different)


Please tick if you wish all correspondence to be sent direct to the Applicant(s)
(If	the	box	is	not	ticked,	all	correspondence	will	be	sent	to	the	introducing	intermediary.)

    6 Telephone number(s) (mandatory)      Work          1234 5678                               Work

                                           Home	         9876 5432                               Home

                                           Mobile                                                Mobile

	 7	E-mail	address
    8 Permanent residency visa number
                                           S1234567A
      (if	applicable)	or	ID	number	(if	
      applicable)
    9 Date of birth (ddmmyy)                 0 | 4           1 | 0           7 | 3                      |          |            |
	
10	Marital	status
11 Relationship or nature of
   interest between the two lives
   to be Assured (if applicable)
12 a Do you have a regular doctor
       or medical practitioner?
                                            Yes     3             No                              Yes            No
	 	 If	yes,	provide	full name and          DR TAN
       address of your regular doctor
       or medical practice/centre          MEDICAL SURGERY
                                                                                        If	your	client	does	not	have	a	regular	doctor,	
       including	fax	number.
                                           TREE ROAD 08-15                                  please	tick	‘No’	–	do	not	leave	blank.
      Please note we might not
      contact your doctor.                 23456 SINGAPORE
      Even if we do, you must
                                           Telephone                     4567 1234               Telephone
      still disclose all facts when
      completing this Application.         Fax	          	               9638 1478               Fax
	     b	 How	long	has	your	regular	
                                                     3             years                                           years
         doctor known you?
      c When did you last attend your
         regular doctor? (ddmmyy)            1 | 4               0 | 1       1 | 1                      |          |            |
      d What was the reason for your       Reason                                                Reason
         last visit?
                                           REGULAR ANNUAL CHECK UP - ALL CLEAR




                                                                                               Clearly write doctors details. Providing a
                                                                                                       fax	number	is	important.	




XSG4/AP 07.11                                                                                                                               Page 4
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 3 – Occupation
                                             First (or only) Life                                    Second Life
1a What is your occupation?
   (If	you	have	more	than	one	
                                              IT MANAGER
   occupation, please provide full
   details of each one)
1b What is the nature of your
   employer’s	business?
                                              FINANCIAL SERVICES
   (eg Financial services, oil and
   natural gas, construction)?
1c Please give details if you work            Full details to include percent of working time        Full details to include percent of working time
   underground, underwater, at                spent	at	heights	and	average	and	maximum	              spent	at	heights	and	average	and	maximum	
   heights over 3 metres, offshore            heights worked at (if applicable.)                     heights worked at (if applicable.)
   or any other hazardous aspects
   of your occupation
                                                                            Where applicable – please provide as much
                                                                            detail as possible. This includes % of time
                                                                             spent	at	heights	and	maximum	height.




Part 4 – Plan details
Required currency               SGD (SG$)   3       USD ($)            HKD	($)             GBP	(£)              EUR	(E)

Premium payable                  Monthly    3       Annually

The	minimum	amount	of	cover	for	any	individual	policy	is	USD400,000	/	SGD650,000	/	GBP225,000	/	HKD3,200,000	/	EUR350,000.

A: How much Life Cover do you require?
BASIS:
A policy for First Life Only                        A policy for Second Life Only                      A policy for Joint Life

Amount of cover         1,000,000                   Amount of cover                                    Amount of cover

         or                                                 or                      Your	client	can	apply	for	different	policies	under	
                                                                                                                 or
                                                                                    the same application, provided the currency
Amount of premium                                   Amount of premium               and premium frequency are the same for each
                                                                                                        Amount of premium
                                                                                    policy.
Term                            20   years          Term                                     years      Term
                                                                                    In	this	case	the	client	is	applying	for:              years
Total and Permanent                                 Total and Permanent                               Total and
                                                                                  – SGD1 million life cover Permanent
Disability	Benefit                                  Disability	Benefit                                Disability	Benefit
Tick	box	if	you	are	placing	                        Tick	box	if	you	are	placing	 – SGD700,000 standalone critical illness cover
                                                                                                                        First	Life
your policy under trust prior                       your policy under trust prior The client will have two policies.
to policy production                                to policy production                                                Second	Life
                                                                                  The policies will start at the same time once the
                                                                                  application has been accepted and will have one
                                                                                                                        Both	Lives
                                                                                  payment method to collect for each policy.
                                                                                                      Tick	box	if	you	are	placing	
                                                                                                      your policy under trust prior
                                                                                                      to policy production

(Guaranteed	premiums.	Maximum	to	age	80.	However,	Total	and	Permanent	Disability	Benefit,	if	selected,	will	cease	on	the	life	
assured’s	65th	birthday).	 	

B: How much Life or Earlier Critical Illness Cover do you require?
BASIS:
A policy for First Life Only                        A policy for Second Life Only                      A policy for Joint Life

Amount of cover                                     Amount of cover                                    Amount of cover

         or                                                 or                                                 or

Amount of premium                                   Amount of premium                                  Amount of premium

Term                                 years          Term                                    years      Term                               years
Tick	box	if	you	are	placing	                        Tick	box	if	you	are	placing	                       Tick	box	if	you	are	placing	
your policy under trust prior                       your policy under trust prior                      your policy under trust prior
to policy production                                to policy production                               to policy production
(Reviewable	premiums,	maximum	to	age	80).




XSG4/AP 07.11                                                                                                                                     Page 5
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 4 – Plan details (continued)
C: How much Critical Illness Cover do you require?
BASIS:
A policy for First Life Only                         A policy for Second Life Only                    A policy for Joint Life

Amount of cover         700,000                      Amount of cover                                  Amount of cover

         or                                                  or                                               or

Amount of premium                                    Amount of premium                                Amount of premium

Term                            20   years           Term                                 years       Term                                years
Tick	box	if	you	are	placing	                         Tick	box	if	you	are	placing	                     Tick	box	if	you	are	placing	
your policy under trust prior                        your policy under trust prior                    your policy under trust prior
to policy production                                 to policy production                             to policy production
(Reviewable	premiums,	maximum	to	age	80)


Start date
Should anything about your health or other circumstances change before Friends Provident International Limited (Singapore Branch)
has assumed risk for the Policy you have applied for, you must tell us immediately. We will then confirm whether any terms we have
quoted will remain available. Failure to notify us of any such change may result in the Policy becoming void and the benefits not
becoming payable.
We will start your Policy immediately if your application is accepted on our normal terms, unless you state a date below on which you would
like it to start or have instructed us otherwise.
If	your	application	is	not	accepted	on	our	normal	terms,	the	Policy	will	not	start	until	we	receive	written	notification	of	your	acceptance	of	any	
revised	terms	Friends	Provident	International	Limited	(Singapore	Branch)	offers,	and	your	instructions	to	go	on	risk.
In	any	event,	risk	cannot	be	assumed	under	the	Policy	before	your	application	is	accepted	by	Friends	Provident	International	Limited	(Singapore	
Branch)	on	normal	terms,	or	Friends	Provident	International	Limited	(Singapore	Branch)	receives	your	acceptance	of	any	revised	terms.
We	also	need	to	have	received	your	first	premium	payment	or	a	completed	Banker’s	Standing	Order,	Interbank	Giro	or	Credit	Card	Authority.
                                                                                        Leave	this	blank	unless	you	wish	cover	
                                                                                             to start on a particular date.
Effective	Date	(ddmmyy)                       |        |           |


Part 5 – Residential and travel details                                                           Please check that the life assured is an
                                             First (or only) Life                                  Second nationality covered by Friends
                                                                                                 acceptable Life
                                                                                                          Provident	International.
1 What are your nationalities?
                                              SINGAPOREAN
  Please list all
2 Country of birth                            SINGAPORE                                          This	section	is	used	to	check	the	client’s	
                                                                                                  eligibility for the contract and any plans
3 Town of birth                               N/A
                                                                                                              to reside elsewhere.
4 What is your current country of
                                              SINGAPORE                                           We do not need to know about trips to
  residence?
                                                                                                  the clients original country lasting less
5 What is the legal basis of your stay                                                                        than 6 months.
  in the current country of residence
  (eg permanent resident visa)?               PERMANENT RESIDENT


6a	How	long	have	you	lived	in	your	
   current country of residence?              34 YEARS
6b	How	long	do	you	intend	to	stay	in	         INDEFINITELY
   your current country of residence?
	 If	you	intend	to	change	your	
   country of residence, please               N/A
   provide full details.
7	 In	which	countries	have	you	lived	
   and for how long?


                                              USA FOR 4 YEARS – STUDYING



                                                                                                           Please provide as much detail as
                                                                                                          possible: include country, region of
8a	Has	your	occupation	involved	                                                                       country ( e.g. cities only), number of trips
   travel outside your current country
                                               Yes    3       No                                     Yes           No
                                                                                                            per annum and length of stay.
   of residence in the last two years?
                                              Details	(Include	countries,	dates	and	durations)          Stating	only	‘	Travel	extensively	in	Asia	‘	
                                                                                                    Details	(Include	countries,	dates	and	durations)
	 If	yes,	please	give	details	including                                                                will mean we will request further details,
   specific countries visited, dates          OCCASIONAL TRIPS TO MALAYSIA                              therefore the progress of the application
   and duration of stay.                      AND INDONESIA - CITIES ONLY - ON                                       may be delayed.
                                              AVERAGE 1 TRIP PER MONTH FOR 3 – 5
                                              DAYS



XSG4/AP 07.11                                                                                                                                     Page 6
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 5 – Residential and travel details (continued)
8b	Do	you	expect	your	occupation	to	
   involve travel outside your current     Yes       3     No                                      Yes            No
   country of residence in the future?
                                          Details (including countries, dates and durations)      Details (including countries, dates and durations)
	 If	Yes,	please	give	details,	
   including specific countries to be     AS PREVIOUS QUESTION - DO NOT
   visited, dates and duration of stay.   EXPECT TRAVEL TO CHANGE




Part 6 – Recreation details
To qualify for ‘non smoker’ status rates you must not have used any form of tobacco or nicotine products within the last 12 months.
                                          First (or only) Life                                   Second Life
1	 Have	you	smoked	or	used	any	
   form	of	tobacco	(for	example	
                                            Yes            No    3                                 Yes            No
   cigarettes, cigars, pipe tobacco)      (Random tests may be carried out to verify non-smoker status)
   or	nicotine	product	(for	example	
   nicotine patches, nicotine gum) in
   the last 12 months?
	 If	yes,	what	form	and	how	much           eg cigarettes, 20 per day                              eg cigarettes, 20 per day
   a day?

	   If	you	have	given	up,	when	did	
    you last use tobacco, what form        2000 – USED TO SMOKE 10 CIGARETTES
    and how much a day did you             A DAY
    previously use?
                                                                                         Please make sure this section is
2a Do you drink alcohol?                    Yes      3     No                                      Yes           No
                                                                                         completed.	If	the	amount	is	zero	
                                                                                         units please state that with a 0.
	   If	yes,	how	many	units	a	week?        Units per week               14                         Units per week
                                          (1 unit = a single measure of spirits or 1 glass of wine (125ml) or 1⁄2 pint (250ml) of beer).
	 b	Have	you	ever	been	advised	by
    a doctor or any other medical
                                            Yes            No    3                                 Yes            No
    practitioner to reduce or stop         Details                                                Details
    your alcohol consumption on
    medical grounds or have you
    ever taken part in counselling,
    therapy or a programme with the
    aim of reducing or stopping your
    alcohol consumption?

3	 In	the	last	7	years	have	you	taken	
   any non-prescription drugs
                                            Yes            No    3                                 Yes            No
   (for	example	LSD,	ecstasy,	             Details                                                Details
   cocaine, heroin, cannabis, anabolic
   steroids etc)?




4 Do you take part in any hazardous
  sport or pastime or do you intend
                                            Yes      3     No                                      Yes            No
  to	start?	(Mountaineering,	motor	        Details                                                Details
  sport, sub-aqua diving and private
  flying	are	examples	but	you	
  should include any activity that         SCUBA DIVING                                 We have a number of sports and
  is	hazardous.	You	do	not	need	                                                        pastime questionnaires. Please
  to include sports such as horse                                                     contact us for a relevant form if your
  riding, skiing, football, rugby,                                                      client has a hazardous pastime.
  hockey, cricket or racquet sports)




XSG4/AP 07.11                                                                                                                                  Page 7
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 7 – Financial details
Where requested please give us as much information as possible in order to avoid needing to go back to you for further clarification.
For higher sums assured we may require further evidence. Where possible we have asked for this to be attached to the proposal form so we
can underwrite this as soon as possible. To determine financial underwriting requirements the following currency conversions will be used:
                      Singapore Dollars            US Dollars               HK	Dollars           British	Pounds                 Euros
                                  1.5M                1.0M                    7.5M                  500,000                    700,000
                                  3.0M                2.0M                    15M                     1.0M                      1.4M
                                  7.5M                5.0M                   37.5M                    2.5M                      3.5M

You are reminded that your answers in this section form part of your application for life assurance and failure to give accurate and
complete answers may result in non-payment of a claim.
                                                 First (or only) Life                                  Second Life
1 Annual earned income                              Currency (eg USD)        SGD                             Currency (eg USD)

                                                          Amount             120,000                               Amount

2a	Please	provide	details	of	any	existing	life,	disability	or	critical	illness	insurance	on	your	life:
   First (or only) life
      Type of cover (e.g.           Country of             Name of insurer                Sum assured        Start date and term         Reason for policy
   Life,	critical	illness,	etc)     insurance                                            (state currency)
             LIFE                  SINGAPORE        AN OTHER INSURANCE CO                 SGD600,000              2007 – WOL       FAMILY PROTECTION




   Second Life
      Type of cover (e.g.           Country of             Name of insurer                Sum assured        Start date and term         Reason for policy
   Life,	critical	illness,	etc)     insurance                                            (state currency)




b Are any of these policies to be                First (or only) Life                                  Second Life
  cancelled once this application is
  in force?                                        Yes            No    3                                   Yes         No

                                                  Company and policy reference                           Company and policy reference




c		 If	total	amount	of	cover	in			               Please tick if attached
	 existence,	plus	this	application,	is		
                                                 (eg	latest	tax	statement,	statement	from	employer,	last	3	months’	payslips)
	 greater	than	either	USD2M	of	life		
    assurance or USD500,000 of critical
    illness insurance, or equivalent,
    please attach evidence of earned
    income for the main earner.




XSG4/AP 07.11                                                                                                                                           Page 8
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 7 – Financial details (continued)
3 Apart from the above, have you
  applied to any other company
                                               Yes            No    3                               Yes           No
  for life, disability or critical illness
                                             Company                                               Company
  insurance in the last 12 months or
  are you about to do so?                    Date                                                  Date
                                             Details including sums assured and reason for         Details including sums assured and reason for
                                             policies                                              policies




                                             Is	only	one	application	to	proceed?                   Is	only	one	application	to	proceed?

4	 Have	you	ever	applied	for	life	
   assurance, insurance against
                                               Yes            No    3                               Yes           No
   ‘critical	illness’	or	income	
                                             Company                                               Company
   protection / disability insurance and
   been turned down or asked to pay          Full details including reason for adverse             Full details including reason for adverse
   a higher premium or have other            decision, company and sum assured                     decision, company and sum assured
   special terms been imposed?




                                             Date                                                  Date

5 Please complete one section from either (a) personal cover or (b) business protection
a) Personal Cover
Complete each appropriate section

3       Personal protection (ie family cover)

                                             First (or only) Life                              Second Life
Please tell us the relationship and
ages of any dependents
                                              WIFE AGE 32
                                              CHILD AGE 3


Please	contact	the	Friends	Provident	International	Limited	Singapore	Branch	to	discuss	requirements	for	sums	assured	greater	than	USD4M	
or equivalent currency.

        Personal loan protection (including mortgage)
What is the reason for the loan?
If	it	is	for	a	mortgage,	please	tell	us
whether it is for your own main
residence or investment.


Name of lender

Amount and duration of loan
Is	the	loan	conditional	on	issue	of
this policy?                                   Yes            No

If	the	sum	assured	is	above	USD1M	for	life	assurance	or	USD500,000	for	critical	illness	
                                                                                                                         Please tick if attached
insurance, or equivalent, please attach a copy of the loan offer letter or evidence of the debt.
b) Business Protection
This includes keyman protection, partnership or shareholder protection or a loan taken out by or on behalf of a business.
What is the reason for the cover and
how was this sum assured derived?




If	the	sum	assured	is	above	USD1M	for	life	assurance	or	USD500,000	for	critical	illness	                                 Please tick if attached
insurance,	or	equivalent,	please	complete	our	Business	Financial	Underwriting	Questionnaire	
and attach to this application.




XSG4/AP 07.11                                                                                                                                      Page 9
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 8 – Family history
First (or only) Life
Before	the	age	of	60,	have	any	of	your	natural	parents,	brothers	or	sisters	had,	or	died	from,	heart	disease,	           Yes   3        No
stroke,	diabetes,	cancer,	Huntington’s	disease,	polycystic	kidney	disease,	polyposis	of	the	colon,	multiple	
sclerosis,	Alzheimer’s	disease,	Parkinson’s	disease,	motor	neurone	disease,	muscular	dystrophy	or	any	
hereditary disorder not already listed above?
If	Yes,	please	complete	the	relevant	section(s)	below	with	details	of	any	of	the	conditions	listed	above.	Please	state	the	age at onset of the
medical condition and in the case of cancer, which part of the body was first affected.

     Relationship to you of person affected                     Medical	condition                           Age at onset of condition
                    FATHER                                          ANGINA                                             59
                   MOTHER                                       BOWEL CANCER                                           53


                                                                                                 It	is	very	important	that	you	provide	age	
                                                                                                 at onset and type of medical condition –
Second Life                                                                                              for	example	type	of	cancer.
Before	the	age	of	60,	have	any	of	your	natural	parents,	brothers	or	sisters	had,	or	died	from,	heart	disease,	           Yes            No
stroke,	diabetes,	cancer,	Huntington’s	disease,	polycystic	kidney	disease,	polyposis	of	the	colon,	multiple	
sclerosis,	Alzheimer’s	disease,	Parkinson’s	disease,	motor	neurone	disease,	muscular	dystrophy	or	any	
hereditary disorder not already listed above?
If	Yes,	please	complete	the	relevant	section(s)	below	with	details	of	any	of	the	conditions	listed	above.	Please	state	the	age at onset of the
medical condition and in the case of cancer, which part of the body was first affected.

     Relationship to you of person affected                     Medical	condition                           Age at onset of condition




XSG4/AP 07.11                                                                                                                                 Page 10
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 9 – Health questions – First (or only) Life
                                                                                   Please answer all questions.
All the questions we ask are relevant and important. You must answer them accurately and completely to the best of your knowledge.
If you do not, we will have the legal right to cancel any policy issued as a result of your application and to not pay any claim.
If the answer to any question is ‘Yes’ please give full details disclosing all facts as they can influence the assessment and acceptance
of the Application.
1 a What is your height?                      178         cm           c Apart from intentional weight loss          Yes         No 3
                                                                          (eg diet) or pregnancy, have you
    b What is your weight?                     84         kg              lost more than 6 kilograms in the
                                                                          last	six	months?
2 Do you currently have or have you ever had any of the following:
a Cancer,	leukaemia,	Hodgkin’s	disease,	lymphoma	or	a	brain	or	spinal	tumour?                                                 Yes          No      3
b	 Heart	disease,	angina,	a	heart	attack,	heart	abnormality	or	defect,	heart	valve	disorder	or	an	irregular	heart	beat?       Yes          No      3
c	 A	stroke,	mini	stroke,	transient	ischaemic	attack	(TIA)	or	a	brain	or	subarachnoid	haemorrhage?                            Yes          No      3
d	 Multiple	sclerosis,	Parkinson’s	disease,	Alzheimer’s	disease,	paralysis	or	paraplegia?                                     Yes          No      3
e Visual disturbance, blurred or double vision, optic or retrobulbar neuritis?                                                Yes          No      3
f Tingling, pins and needles, numbness, a tremor or any loss of feeling, balance or coordination,
  for which you consulted a doctor or hospital?
                                                                                                                              Yes          No      3
g	 Have	you	ever	tested	positive	for	HIV,	Hepatitis	B	or	C	or	are	you	awaiting	the	results	of	such	a	test?                    Yes          No      3
(If	the	result	was	negative,	the	fact	of	having	an	HIV	test	will	not	in	itself	have	any	effect	on	your	acceptance	terms	for	insurance)

Question	       Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	    Name,	address,	tel/fax	of	doctor	
Reference       investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	          or clinic/hospital attended.
                necessary.




3 In the last 5 years have you had any of the following:
a Any lump that has appeared or grown in size, or a mole or freckle that has bled, caused pain or changed
  in appearance?
                                                                                                                              Yes          No      3
b Raised blood pressure or raised cholesterol for which treatment, further readings or a change in diet                       Yes          No      3
  were advised?
c Asthma, bronchitis, tuberculosis, coughing with blood or any chest, lung or breathing disorder?                             Yes          No      3
d Recurrent headache for which you have consulted a doctor or any epilepsy, seizure, fit or blackout?                         Yes          No      3
   A
e	 	 ny	impairment	of	vision	or	hearing	or	any	disorder	of	the	eyes	or	ears?	(You	may	ignore	sight	problems	corrected		
   by glasses or contact lenses but you must tell us about all hearing problems, even if corrected by hearing aid(s))
                                                                                                                              Yes          No      3
f	 Back	pain,	neck	pain,	sciatica,	joint	pain,	arthritis,	repetitive	strain	injury	or	any	other	disorder	of	the	muscles,			   Yes          No      3
   bones or limbs for which you have consulted a doctor, hospital, physiotherapist, osteopath, chiropractor or any
   other type of medical practitioner or for which you have taken time off work?
g	 Diabetes,	Crohn’s	disease	or	colitis?	                                                                                     Yes          No      3
h Any disorder of the kidneys?                                                                                                Yes          No      3
i	 Treatment	or	a	positive	test	for	any	disease	which	was	transmitted	sexually?	                                              Yes          No      3
j (i) Any mental illness or eating disorder or have you attempted self-harm or taken an overdose?                             Yes          No      3
      A
	 (ii)	 ny	other	feeling	of	depression,	anxiety,	stress	or	fatigue	that	you	have	reported	to	a	doctor,	hospital,	nurse,		
      psychologist or psychiatrist or any other type of medical practitioner?
                                                                                                                              Yes          No      3
   W
k	 	 ithin	the	last	5	years	have	you	been	exposed	to	the	risk	of	HIV	infection?                                               Yes          No      3
   (
	 	HIV	can	be	caught	through	unsafe	sex,	intravenous	drug	abuse,	or	blood	transfusions	outside	Singapore	or	
   surgery undertaken outside Singapore)

Question	       Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	    Name,	address,	tel/fax	of	doctor	
Reference       investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	          or clinic/hospital attended.
                necessary.




XSG4/AP 07.11                                                                                                                                   Page 11
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 9 – Health questions – First (or only) Life (continued)
4 In the last 2 years, other than for those conditions you have already mentioned:
                                                                                                                                                           J TAN
a Have	you	had	any	medical	consultation	(for	example	with	a	doctor,	consultant,	psychiatrist,	clinic,			           	         Yes   3       No      3      19/7/11
  physiotherapist or any other type of medical practitioner) or attendance at a hospital as an inpatient or outpatient?
b	 Have	you	had,	or	been	advised	to	have,	any	medical	investigation,	x-ray,	scan	or	test?	                                   Yes           No      3
   (For this question, you do not need to give details of occasional consultations with your regular doctor for colds,
   flu, or consultations for oral contraceptive pills, smear tests, well man/woman check-ups where the results are
   known and were normal)

 Question	      Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	    Name,	address,	tel/fax	of	doctor	
 Reference      investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	          or clinic/hospital attended.
                necessary.                                                                                          DR TAN
                                                                     Please provide as much detail as possible      MEDICAL SURGERY
 4A             FOR MY ANNUAL CHECK UP – ALL CLEAR                     to include: doctor name, department/         TREE ROAD 08-15
                                                                         speciality, clinic/hospital address,       23456 SINGAPORE
                                                                          telephone	number,	fax	number.             TEL: 4567 1234
                                                                                                                    FAX: 9638 1478

5 In the last 12 months have you been prescribed any drug, medicine or tablet, or have you had any other form                Yes           No      3
  of	medical	treatment	(for	example	physiotherapy,	psychotherapy)?

6 In the last 6 months have you had any medical symptom, change in your physical or mental health or change
  in your physical or mental ability for which you have not consulted a doctor, hospital or medical practitioner?
                                                                                                                             Yes           No      3
  (For this question, you do not need to give details of colds and flu which have lasted less than 2 weeks in total)
7 In the next 12 months are you due to have any consultation or check-up in connection with any medical
  symptom or condition, or are you waiting for the result of any medical investigation?
                                                                                                                             Yes           No      3
8 Other than the information you have already provided, have you ever had an illness or medical condition
  that has lasted more than 3 months and which affected your ability to study or perform normal daily activities
                                                                                                                             Yes           No      3
  or for which you took more than 2 weeks off work?

 Question	      Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	    Name,	address,	tel/fax	of	doctor	
 Reference      investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	          or clinic/hospital attended.
                necessary.




 Additional information

                                                                                                   If	your	client	makes	any	amendment	to	their	
                                                                                                    answers, ensure the amendment is signed
                                                                                                   and dated. Any additional information should
                                                                                                              be	written	within	this	box.




If	you	require	more	space	to	write	your	answers,	please	attach	an	additional	sheet	to	this	application.

Additional sheet attached                    Yes            No    3


XSG4/AP 07.11                                                                                                                                   Page 12
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 9 – Health questions – Second Life
All the questions we ask are relevant and important. You must answer them accurately and completely to the best of your knowledge.
If you do not, we will have the legal right to cancel any policy issued as a result of your application and to not pay any claim.
If the answer to any question is ‘Yes’ please give full details disclosing all facts as they can influence the assessment and acceptance
of the Application.
1 a What is your height?                                  cm           c Apart from intentional weight loss          Yes         No
                                                                          (eg diet) or pregnancy, have you
    b What is your weight?                                kg              lost more than 6 kilograms in the
                                                                          last	six	months?
2 Do you currently have or have you ever had any of the following:
a Cancer,	leukaemia,	Hodgkin’s	disease,	lymphoma	or	a	brain	or	spinal	tumour?                                                 Yes          No

b	 Heart	disease,	angina,	a	heart	attack,	heart	abnormality	or	defect,	heart	valve	disorder	or	an	irregular	heart	beat?       Yes          No

c	 A	stroke,	mini	stroke,	transient	ischaemic	attack	(TIA)	or	a	brain	or	subarachnoid	haemorrhage?                            Yes          No

d	 Multiple	sclerosis,	Parkinson’s	disease,	Alzheimer’s	disease,	paralysis	or	paraplegia?                                     Yes          No

e Visual disturbance, blurred or double vision, optic or retrobulbar neuritis?                                                Yes          No
f Tingling, pins and needles, numbness, a tremor or any loss of feeling, balance or coordination,
                                                                                                                              Yes          No
  for which you consulted a doctor or hospital?
g	 Have	you	ever	tested	positive	for	HIV,	Hepatitis	B	or	C	or	are	you	awaiting	the	results	of	such	a	test?                    Yes          No
(If	the	result	was	negative,	the	fact	of	having	an	HIV	test	will	not	in	itself	have	any	effect	on	your	acceptance	terms	for	insurance)

Question	       Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	    Name,	address,	tel/fax	of	doctor	
Reference       investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	          or clinic/hospital attended.
                necessary.




3 In the last 5 years have you had any of the following:
a Any lump that has appeared or grown in size, or a mole or freckle that has bled, caused pain or changed
                                                                                                                              Yes          No
  in appearance?
b Raised blood pressure or raised cholesterol for which treatment, further readings or a change in diet                       Yes          No
  were advised?
c Asthma, bronchitis, tuberculosis, coughing with blood or any chest, lung or breathing disorder?                             Yes          No

d Recurrent headache for which you have consulted a doctor or any epilepsy, seizure, fit or blackout?                         Yes          No
   A
e	 	 ny	impairment	of	vision	or	hearing	or	any	disorder	of	the	eyes	or	ears?	(You	may	ignore	sight	problems	corrected		
                                                                                                                              Yes          No
   by glasses or contact lenses but you must tell us about all hearing problems, even if corrected by hearing aid(s))
f	 Back	pain,	neck	pain,	sciatica,	joint	pain,	arthritis,	repetitive	strain	injury	or	any	other	disorder	of	the	muscles,			   Yes          No
   bones or limbs for which you have consulted a doctor, hospital, physiotherapist, osteopath, chiropractor or any
   other type of medical practitioner or for which you have taken time off work?
g	 Diabetes,	Crohn’s	disease	or	colitis?	                                                                                     Yes          No

h Any disorder of the kidneys?                                                                                                Yes          No

i	 Treatment	or	a	positive	test	for	any	disease	which	was	transmitted	sexually?	                                              Yes          No

j (i) Any mental illness or eating disorder or have you attempted self-harm or taken an overdose?                             Yes          No
      A
	 (ii)	 ny	other	feeling	of	depression,	anxiety,	stress	or	fatigue	that	you	have	reported	to	a	doctor,	hospital,	nurse,		
                                                                                                                              Yes          No
      psychologist or psychiatrist or any other type of medical practitioner?
   W
k	 	 ithin	the	last	5	years	have	you	been	exposed	to	the	risk	of	HIV	infection?                                               Yes          No
   (
	 	HIV	can	be	caught	through	unsafe	sex,	intravenous	drug	abuse,	or	blood	transfusions	outside	Singapore	or	
   surgery undertaken outside Singapore)

Question	       Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	    Name,	address,	tel/fax	of	doctor	
Reference       investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	          or clinic/hospital attended.
                necessary.




XSG4/AP 07.11                                                                                                                                   Page 13
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 9 – Health questions – Second Life (continued)
4 In the last 2 years, other than for those conditions you have already mentioned:
a Have	you	had	any	medical	consultation	(for	example	with	a	doctor,	consultant,	psychiatrist,	clinic,			           	        Yes           No
  physiotherapist or any other type of medical practitioner) or attendance at a hospital as an inpatient or outpatient?
b	 Have	you	had,	or	been	advised	to	have,	any	medical	investigation,	x-ray,	scan	or	test?	                                  Yes           No
   (For this question, you do not need to give details of occasional consultations with your regular doctor for colds,
   flu, or consultations for oral contraceptive pills, smear tests, well man/woman check-ups where the results are
   known and were normal)

 Question	      Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	   Name,	address,	tel/fax	of	doctor	
 Reference      investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	         or clinic/hospital attended.
                necessary.




5 In the last 12 months have you been prescribed any drug, medicine or tablet, or have you had any other form               Yes           No
  of	medical	treatment	(for	example	physiotherapy,	psychotherapy)?

6 In the last 6 months have you had any medical symptom, change in your physical or mental health or change
                                                                                                                           Yes            No
  in your physical or mental ability for which you have not consulted a doctor, hospital or medical practitioner?
  (For this question, you do not need to give details of colds and flu which have lasted less than 2 weeks in total)
7 In the next 12 months are you due to have any consultation or check-up in connection with any medical
                                                                                                                            Yes           No
  symptom or condition, or are you waiting for the result of any medical investigation?

8 Other than the information you have already provided, have you ever had an illness or medical condition                   Yes           No
  that has lasted more than 3 months and which affected your ability to study or perform normal daily activities
  or for which you took more than 2 weeks off work?

 Question	      Please	list	in	this	box	the	disorder(s),	date	of	disorder(s)	and	duration,	treatment,	result	of	   Name,	address,	tel/fax	of	doctor	
 Reference      investigations,	time	off	work	and	when.	Continue	in	the	box	at	the	end	of	this	section	if	         or clinic/hospital attended.
                necessary.




 Additional information




If	you	require	more	space	to	write	your	answers,	please	attach	an	additional	sheet	to	this	application.

Additional sheet attached                    Yes            No



XSG4/AP 07.11                                                                                                                                  Page 14
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 10 – Applicant(s) details –                      The Applicant(s) is/are the person(s) who are to be the owner(s) of the Policy.

Is/Are	the	applicant(s):	

3    the first or only life assured?                                                       Only complete this section if the
                                                                                       policyholder is to be someone different
     the second life assured?                        Please go to Part 11                     from the life/lives assured.

     both lives assured?

     neither life/lives assured? If neither, please complete Part 10 in full.

                                         First (or only) Applicant                                Second Applicant

	 1	Title	eg	Mr,	Mrs,	Dr,	Miss

                                           Male                    Female                           Male               Female

 2 Surname

 3 First name(s)

 4 Company/Trust name
 5 Current residential address
   (including street name, town and
   area code if known)




 6 Telephone number(s)                    Work                                                     Work

                                          Home                                                     Home

                                          Mobile                                                   Mobile

	 7	E-mail	address

	 8	ID	number/Passport	number

 9 Date of birth (ddmmyy)                        |             |            |                          |           |             |
	
10	Marital	status

11 Nationality

12 Place or town of birth

13 Country of birth
14 Country of permanent residence
   (if different from above)
15 Relationship or nature of interest                              This could be as follows:
   in the person(s) named in Part 2                                SPOUSE	–	FINANCIAL	DEPENDENCY	KEY	PERSON	TO	COMPANY	–	VALUE


If	you	require	more	space	to	write	your	answers,	please	attach	an	additional	sheet	to	this	application.

Additional sheet attached                  Yes               No




XSG4/AP 07.11                                                                                                                           Page 15
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 11 – Access to Existing Medical Reports
Please note we might not contact your doctor. Even if we do, you            •	 Any	history	of	disease	among	your	parents	or	brothers	or	sisters	
must still disclose all the facts when completing this Application.            that you have told your doctor about.
We may need to get medical reports to support your Application.             We ask your doctor not to reveal information about:
Before	we	can	ask	any	doctor	that	you	have	consulted	to	fill	in	a	
report, we need your permission.                                            •	 Negative	tests	for	HIV,	hepatitis	B	or	C;	or

You	do	not	need	to	give	your	permission,	but	if	you	do	not,	we	may	         •	 Any	sexually-transmitted	diseases	unless	there	could	be	long-term	
not be able to go ahead with your Application. This does not prevent           effects on your health.
you from applying to other companies for insurance.                         The information you and your doctor provide about your health may
You	can	ask	to	see	the	report	before	the	doctor	returns	it	to	us;           result in us:
if this is the case, we will tell the doctor to keep the report for         •	 Refusing	to	provide	insurance;
21	days	so	that	you	can	arrange	to	see	it.	If	you	have	not	made	
arrangements to see the report within this time, your doctor will send      •	 Increasing	premiums	above	standard	rates;
the report to us.
                                                                            •	 Applying	an	exclusion	to	the	cover;	or
If	you	choose	not	to	see	the	report	at	this	stage,	you	may	ask	the	
doctor	for	a	copy	within	six	months	of	it	being	sent	to	us.	We	can	         •	 Setting	premiums	at	standard	rates.
send a copy of the report to your doctor if you ask to see it at a          If	you	have	any	questions	relating	to	the	process	of	getting,	
later date.                                                                 assessing or storing medical information, please write to:
If	you	think	that	any	part	of	the	report	is	not	factually	correct	or	is	    The	Chief	Medical	Officer,	c/o	Friends	Provident	International	Limited	
misleading,	you	may	ask	the	doctor	to	amend	it.	If	your	doctor	             (Singapore	Branch),	63	Market	Street,	#06-05,	Bank	of	Singapore	
refuses to make the amendments, you may ask him or her to                   Centre, Singapore 048942.
attach a statement outlining your views, which will then accompany
the report.
Your	doctor	can	withhold	from	you	access	to	the	report	if	he	or	she	
feels that it would cause physical or mental harm to you or others.                   Please ensure your client reads this
                                                                                               section carefully.
The medical report your doctor fills in asks about the following:
                                                                                     Access does not apply to any medical
•	 Your	current	health                                                             examination	and	tests	required	in	respect	
   – Any care, medication or treatment you are currently receiving.                           of this application.

   – The results of referrals or tests you are waiting for.
•	 Any	time	off	work	in	the	last	three	years.
•	 Your	past	health
   – Details of any relevant illness, trauma, or referrals for specialist
     advice or treatment, hospital admissions, consultations with
     your doctor or any other medical adviser, therapist or
     counsellor, in particular whether you have a history of:
       –	 Malignancy	(cancer),	cardiovascular	(heart)	disease,	
          diabetes, and degenerative (gradually worsening) diseases;
       –	 Musculoskeletal	disease	or	injury,	for	example,	arthritis,	
          rheumatism, back problems or any other disorder of the
          joints or muscles;
       –	 Anxiety,	depression,	neurosis	(such	as	phobias,	obsessions	
          and so on), psychosis (a mental disorder where you lose
          contact with reality), stress or fatigue;
       – Suicidal thoughts or attempts at suicide; or
       – Conditions related to drug or alcohol misuse or smoking
         or chewing tobacco
       – Details of any biopsies, blood tests, electrocardiograms
         (heart tests), height, weight if measured in the last two
         years,	urinalyses	(tests	on	urine),	x-rays	or	other	
         investigations
       – Any blood pressure readings in the last three years




XSG4/AP 07.11                                                                                                                                 Page 16
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 12 – Declaration               This Declaration must be signed by all persons involved in this Application.
1	 •	 This	Application	is	my	official	request	to	enter	into	a	contract	      	   •	 I	understand	and	accept	that	where	I	am	applying	on	the	advice	
      with	Friends	Provident	International	Limited	(Singapore	Branch)	              of a Financial Adviser, that adviser is acting on my behalf and
      together	providing	the	foregoing	Policy.	I	understand	and	accept	             not	as	an	agent	of	Friends	Provident	International	Limited	
      that	the	contract	will	be	on	Friends	Provident	International	                 (Singapore	Branch).
      Limited	(Singapore	Branch)	normal	terms	and	conditions.
                                                                             5	 •	 I	understand	that	Friends	Provident	International	Limited	
	   •	 I	understand	and	accept	that	Friends	Provident	International	               (Singapore	Branch)	will	report	this	business	in	its	register	of	
       Limited	(Singapore	Branch)	is	subject	to	the	supervisory	                   Singapore policies.
       arrangements and law of Singapore.
                                                                             6	 •	 I have read Part 1 – Introduction and my answers to the
	   •	 I	understand	that	the	Policy	shall	be	governed	by	the	law	of	               questions in this Application and declare that, to the best of
       Singapore.                                                                  my knowledge and belief, all the information I have given is
                                                                                   true and that no fact has been withheld. I understand I
	   •	 I	understand	and	accept	that	this	application	can	only	be	                  must ensure that all facts I disclosed to my Financial
       accepted	by	employees	of	Friends	Provident	International	                   Adviser in answer to the questions in this Application are
       Limited	(Singapore	Branch)	situated	at	63	Market	Street,	                   accurately recorded in this Application. I understand and
       #06-05,	Bank	of	Singapore	Centre,	Singapore	048942	and	that	                accept that failure to disclose a fact or the giving of false
       no other employees or third parties have the necessary                      information will give Friends Provident International
       authority to create a binding contract.                                     Limited (Singapore Branch) the right to cancel from
2	 •	 I	understand	and	accept	Friends	Provident	International	Limited	             inception any policy issued as a result of this Application
      (Singapore	Branch)	may	require	sight	of	my	medical	records	to	               and may invalidate any future claim.
      consider a claim.                                                          • I understand that I must tell Friends Provident International
	   •	 I	authorise	any	doctor,	physician,	practitioner,	hospital,	clinic,	         Limited (Singapore Branch) without delay if my health or
       insurance or reinsurance company, employer, other individual                circumstances change before Friends Provident
       organisation or government office that has any records or                   International Limited (Singapore Branch) assumes risk for
       knowledge of me or my health to disclose to Friends Provident               the Policy applied for.
       International	Limited	(Singapore	Branch)	any	information	for	         7	 •	 I	accept	that	if	I	am	required	to	have	a	medical	examination,	
       the purpose of considering a claim. This authorisation shall                the	replies	to	the	medical	examiner’s	questions	will	form	part	
       irrevocably bind my successors and assigns and remain valid,                of this Application.
       notwithstanding my death or incapacity, and a copy of this
       authorisation shall be as effective and valid as the original.        	   •	 I	agree	Friends	Provident	International	Limited	(Singapore	
                                                                                    Branch)	will	use	the	information	I	give	(as	well	as	information	
3	 •	 I	understand	that	information	given	to	Friends	Provident	                     about	me	relating	to	any	existing	policy	I	may	have	with	Friends	
      International	Limited	(Singapore	Branch)	in	connection	with	this	             Provident	International	Limited)	for	administration,	underwriting,	
      Application	may	be	used	by	Friends	Provident	International	Limited	           claims,	research	and	statistical	purposes.	I	authorise	Friends	
      in its consideration of any claim in future and may be shared with            Provident	International	Limited	(Singapore	Branch)	to	pass	
      a	third	party	eg	medical	examiner,	to	help	in	the	assessment	of	a	            information	including	medical	information	to	medical	examiners	
      claim.                                                                        and practitioners, underwriters, claims investigation companies,
	   •	 I	understand	that	Friends	Provident	International	Limited	                   life insurance or reinsurance companies, data processors and to
       (Singapore	Branch)	will	pass	the	information	about	any	                      any company or agency appointed for these purposes. (These
       claim concerning critical or disability illness insurance to the             companies or agencies may be located in countries that do not
       Association	of	British	Insurers	(ABI)	so	that	they	can	make	it	              have laws to protect your information. Friends Provident
       available	to	other	insurers.	I	also	understand	that,	in	response	            International	Limited	(Singapore	Branch)will	remain	responsible	
       to any searches you make in connection with this claim,                      for making sure that the information is held securely.)
       the	ABI	may	pass	you	information	it	has	received	from	                	   •	 I	also	agree	Friends	Provident	International	Limited	(Singapore	
       other insurers.                                                              Branch)	may	pass	the	information	to	third	parties	for	the	
4	 •	 I	am	satisfied	that	to	the	best	of	my	knowledge	and	belief	I	am	not	          prevention of crime or detection of fraud, enabling assets to be
      subject to any legislation which would make this policy unlawful.             rightfully claimed or where required by law or regulation.

	   •	 I	understand	and	accept	that	the	terms	and	conditions	and	a	
       copy of this completed Application are available on request.




XSG4/AP 07.11                                                                                                                                     Page 17
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 12 – Declaration (continued)                       This Declaration must be signed by all persons involved in this Application.

8	 •	 I	agree	to	Friends	Provident	International	Limited	(Singapore	            	   •	 If	the	life	assured	does	not	want	to	view	the	report	before	
      Branch)	asking	any	doctor	I	have	consulted	about	my	physical	                    it	is	sent	to	the	company,	leave	the	next	section	blank.
      or mental health to provide medical information so you may
      assess	this	Application.	Friends	Provident	International	Limited	             •   As	Life	Assured,	I	do want to see      Life	1        Life	2
      (Singapore	Branch)	may	gather	relevant	information	from	other	                    the report before it is sent to the
      insurers about any other Applications for life, critical illness,                 company
      sickness, disability, accident or private medical insurance on
                                                                             10	•	 I	have	received	a	copy	of	‘Your	Guide	to	Life	Assurance’,	‘Fact	
      my	life	that	I	have	applied	for.	I	authorise	those	asked	to	
                                                                                   Find’,	product	summary	and	benefit	illustration,	the	content	of	
      provide medical and policy information when they see a copy
                                                                                   which	have	been	explained	to	my	satisfaction.
      of this consent form.
                                                                             11	•	 I	have	received	a	copy	of	‘Your	Guide	to	Health	Insurance’	
9	 •	 I have read and understood Part 11 relating to Access to                                          Please tick if the client does want to see
                                                                                   (only	applicable	if	any	form	of	Critical	Illness	Cover	is	being	
      Existing Medical Reports. I understand this does not apply                                          any	report	from	their	existing	medical	
                                                                                   applied for).
      to any medical examination and tests I may be required to                                               records before it is sent to us.
      have in respect of this application.



 If a material fact is not disclosed in this application, any policy issued may not be valid. If you are in doubt as to whether a fact is
 material, you are advised to disclose it. This includes any information that you may have provided to the financial adviser but was
 not included in the application. Please check to ensure that you are fully satisfied with the information declared in this application.




First (or only) Life                                                     Second Life
(who will also be the Applicant if Part 10 is not completed)             (who will also be the Applicant if Part 10 is not completed)
 Signature                                      Please ensure the correct Signature
                                 J TAN           box	is	signed	and	dated	
                                                   for each life assured.

Please print name     JAMES TAN                                             Please print name

Date (ddmmyy)        1 | 9     0 | 7     1 | 1                              Date (ddmmyy)            |         |         |
*	Application	must	be	received	by	Friends	Provident	International	Limited	(Singapore	Branch)	within	six	weeks	of	the	date	of	signing              Important

Only complete the following if Part 10 completed
First Applicant (if applicable)                                             Second Applicant (if applicable)
 Signature                                                                   Signature



Date (ddmmyy)           |         |         |                               Date (ddmmyy)            |         |         |
If signing on behalf of a Company or partnership please state in what capacity you are signing (eg Company Secretary)

 Capacity                                                                    Capacity

Representative’s Declaration
I	declare	that	the	information	provided	to	me	in	this	Application	Form	is	strictly	confidential	and	is	only	to	be	used	for	the	purpose	of	fact-finding	
in the process of recommending suitable insurance products, and shall not be used for any other purposes.

 I	declare	that	all	the	answers	provided	to	me	by	the	applicant/life	to	be	assured	are	declared	on	this	proposal.	I	have	not	withheld	any	other	
 information	which	may	influence	the	acceptance	of	this	proposal	by	Friends	Provident	International	Limited	(Singapore	Branch).

 Signature of Representative
                                  M BROKER                                  Date (ddmmyy)         1 | 9     0 | 7     1 | 1




XSG4/AP 07.11                                                                                                                                   Page 18
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 13 – Payment Details
GUIDANCE	NOTES:	Please complete in BLOCK CAPITALS the section which is appropriate for your method of payment and return the
form,	along	with	your	application	form,	to	your	Financial	Adviser	or	Friends	Provident	International	Limited	(Singapore	Branch).	DO NOT send
the completed form to your Bank or Building Society.
WARNING:	Please	note	that	cash	is	not	acceptable	as	a	premium	payment	method.	Any	payments	made	in	cash	may not be returned.
For monthly payments	(available	for	5	year	terms	or	more	only)	a	Banker’s	Standing	Order,	Interbank	Giro	from	a	local	bank	account	
(singapore	dollar	payments	only),	and	credit	card	authority	(VISA,	Eurocard	&	Mastercard	only)	are	acceptable	methods	of	payment.	For	
annual payments	a	Banker’s	Standing	Order,	Interbank	Giro	from	a	local	bank	account	(singapore	dollar	payments	only),	draft	and	telegraphic	
transfer are acceptable.

 For Annual Payments by Telegraphic Transfer complete Section A.
 For	Annual	Payments	by	Banker’s	Draft	complete	Section	B.
 For	Monthly	or	Annual	Payments	by	Banker’s	Standing	Order	complete	Section	C.                           Please complete for all cases
 For	Monthly	or	Annual	Payments	by	Credit	Card	complete	the	relevant	section	overleaf
 Please sign Section D in all cases                                                                       where the premium is NOT
                                                                                                        being paid for by Credit Card or
* Please delete as appropriate                                                                                  Interbank	Giro.
                                                       Bank Instruction Letter
To be completed in all cases unless paying by Credit Card or Interbank Giro. Please note that some banks insist that their own Bank
Instruction form is used, so you should check with your bank that they will accept this document.
Name	and	full	postal	address	of	your	Bank                                   Sort Code (if applicable)
 To:	The	Manager	                                                    Bank
 Address	(PO	Box	mandatory)                                                 SWIFT/BIC	Code	(if	applicable)


 Postcode                                                                   IBAN	(if	applicable)

 Telephone (mandatory)
                                                                            Account Number


                                                                            Account Name


PLEASE LEAVE ALL AMOUNT AND DATE BOXES BLANK.                               Account Currency (must be completed if the account is multi-currency)
FRIENDS PROVIDENT INTERNATIONAL LIMITED WILL
COMPLETE THESE ONCE THE PREMIUM AMOUNT IS FINALISED.

Section A – Telegraphic Transfers
Dear Sir,
On my/our* behalf please prepare a Telegraphic Transfer and carry out the transaction indicated within 48 hours of you receiving this instruction.
The	reference	number	below	(see	Section	D)	must	be	quoted	by	the	Bank	on	all	advices.
 SG$/US$/HK$/£/E*                              (figures)      SG$/US$/HK$/£/E*                                                              (words)
Please charge the amount of the payment together with any bank and agent bank’s charges to my/our* account.

Section B – Drafts
Dear Sir,
On my/our* behalf please prepare a Draft and carry out the transaction indicated    within 48 hours of you receiving this instruction.
On	receipt	of	this	letter	please	prepare	a	(tick	one	box	only)
     HK	Dollar	Draft	            US Dollar Draft          SG Dollar Draft             Sterling Draft                   Euro	Draft	(drawn	on	a	bank	
     (drawn on a bank            (drawn on a bank         (drawn on a bank            (drawn on a bank in              in	European	Economic	and	
     in	Hong	Kong)               in	New	York)             in Singapore)               the	United	Kingdom)              Monetary	Union	(EMU))
payable to Friends Provident International Limited (Singapore Branch), quoting	the	reference	given	below,	for	exactly
                                               (figures)                                                                                    (words)
USD,	GBP	&	Euro	Drafts:	After	preparation	of	the	Draft	please	airmail	it	at	my/our*	own	cost,	together	with	a	copy	of	this	instruction,
immediately	to	Friends	Provident	International	Limited,	Royal	Court,	Castletown,	Isle	of	Man	IM9	1RA,	British	Isles.
SGD Drafts: After preparation of the Draft please airmail it at my/our* own cost, together with a copy of this instruction, immediately to
Friends	Provident	International	Limited	(Singapore	Branch).	
HKD	Drafts:	After	preparation	of	the	Draft	please	airmail	it	at	my/our*	own	cost,	together	with	a	copy	of	this	instruction,	immediately	to	
                                                                                                        Please leave the amount payable
Friends	Provident	International	Limited,	Suites	1203-1211,	Two	Pacific	Place,	88	Queensway,	Hong	Kong. the start date blank as these
                                                                                                         and
                                                                                                        details could change following the
Section C – Banker’s Standing Order                                                                       underwriting of the application.
Dear Sir,
On	my/our*	behalf	please	pay	by	Bankers’	remittance	and	carry	out	the	transaction	indicated	within	48	hours	of	you	receiving	
this instruction. Please charge the amount of the payment below and any bank and agent bank’s charges to my/our* account.
 SG$/US$/HK$//£/E*                             (figures)      SG$/US$/HK$//£/E*                                                             (words)

on the               day of                                (month)                    (year) and on the same day             monthly       annually

Section D                                                                   My/Our*	Address

Yours	faithfully,	               J TAN
Signature(s)
Date (ddmmyy)                 1 | 9    0 | 7     1 | 1
This	Reference	Number	must	be	quoted	by	the	Bank	on	all	advices	(to	be	
completed	by	Friends	Provident	International	Limited)

XSG4/AP 07.11                                                                                                                                 Page 19
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 13 – Payment Details (continued)
Our bank details
HSBC	Singapore,	21	Collyer	Quay,	#01-01	HSBC	Building,	Singapore	049320

SGD             Account Number: 147-110001-004         Account Name:	FPIL	(SG	BR)-G	TERM	P	AC	SGD
GBP             Account Number: 260-592290-179         Account Name:	FPIL	(SG	BR)-G	TERM	P	AC	GBP
USD             Account Number: 260-592290-178         Account Name:	FPIL	(SG	BR)-G	TERM	P	AC	USD
HKD             Account Number: 260-592290-180         Account Name:	FPIL	(SG	BR)-G	TERM	P	AC	HKD
EUR             Account Number: 260-592290-181         Account Name:	FPIL	(SG	BR)-G	TERM	P	AC	EUR




XSG4/AP 07.11                                                                                       Page 20
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM

Application for Interbank Giro                   (only available in SGD for clients with local bank accounts)
Please	allow	up	to	six	weeks	to	set	up	the	direct	debit	arrangement.	Cheque	payment	cannot	be	combined	with	this	payment	method.

Section E – For Applicant’s Completion
Effective	Date	
(ddmmyyyy)                               |           |               |       |       |
To:	The	Manager                                                                              Name	of	Billing	Organisation	(‘BO’)
(Name	&	Address	of	My/Our	Bank/Finance	Company)                                               FRIENDS PROVIDENT INTERNATIONAL LIMITED

                                                                                             Billing	Organisation’s	Customer’s	Name


                                                                                                                                  Only complete if the policy
                                                                                             Billing	Organisation’s	Customer’s	Reference	Number	(Leave	blank)
                                                                                                                             denomination is SGD and your client
                                                                                                                            has a SGD bank account in Singapore.

a)	 I/We	hereby	instruct	you	to	process	the	BO’s	instructions	to	debit	my/our	account.
b)	 You	are	entitled	to	reject	the	BO’s	debit	instruction	if	my/our	account	does	not	have	sufficient	funds	and	charge	me/us	a	fee	for	this.	You	
    may also at your discretion allow the debit even if this results in an overdraft on the account and impose charges accordingly.
c) This authorisation will remain in force until terminated by your written notice sent to my/our address last known to you or upon receipt of
   my/our	written	revocation	through	the	BO.

My/Our	Name(s)                                                                               My/Our	Contact	(Tel/Fax)	Number(s)


My/Our	Account	Number                                                                        My/Our	Company	Stamp/Signature(s)/Thumbprint(s)*
Bank                 Branch           Billing	Organisation’s	Account	Number
    |     |     |           |   |        |   |   |       |   |   |       |   |   |       |
                                                                                                             J TAN
Date of signature (ddmmyyyy)

  1 | 9             0 | 7           2 | 0 | 1 | 1                                            (As	in	Financial	Institution’s	records)


Section F – For Billing Organisation’s Completion
Bank                 Branch           Billing	Organisation’s	Account	Number                  Billing	Organisation’s	Customer’s	Reference	Number

 7 | 2 | 3 | 2         1 | 4 | 7       1 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 4 |               |       |       |   |   |       |   |   |       |       |   |       |


Section G – For Financial Institution’s Completion
To:	Billing	Organisation
This	application	is	hereby	REJECTED	(please	tick)	for	the	following	reason(s):

        Signature/Thumbprint#	differs	from	Financial	Institution’s	records                           Wrong account number

        Signature/Thumbprint# incomplete/unclear#                                                    Amendments not countersigned by customer

        Account operated by signature/thumbprint#                                                    Others (please specify below)

Name of Approving Officer




Authorised Signature                                                                         Date (ddmmyyyy)
                                                                                                     |               |               |       |           |



* For thumbprints, please go to the branch with your identification.
# Please delete where inapplicable.




XSG4/AP 07.11                                                                                                                                                    Page 21
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM




XSG4/AP 07.11                                                                 Page 22
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Part 13 – Payment Details (continued)




                                                                                                         Only complete if the premium is to
                                                                                                         be paid by Credit Card. Debit Card
                                                                                                            payments are not accepted.
Credit Card Authority                  This form supersedes any previous instructions held.

Please	use	BLOCK	CAPITALS
I	authorise	Friends	Provident	International	Limited	(Singapore	Branch)	to	charge	the	premium	below,	to	my	credit	card	account	for	this	
insurance	policy.	This	authorisation	is	to	remain	in	effect	until	I	cancel	it	by	written	notification	to	Friends	Provident	International	Limited	
(Singapore	Branch)	at	least	30	days	in	advance	of	the	intended	date	of	cancellation.


Name of Cardholder                                                           Bank

Credit Card Number

Expiry	date	(mmyy)                 |           |                                    Mastercard            VISA	Credit	Card                Eurocard
with sum of (premium
amount if known)
                             Please leave blank*
Currency
Collected on the (premium                                                    and on the same day
due date) (ddmmyy)                 |           |            |                until further notice         monthly                         yearly

Address of Credit Card       Please leave blank*
Holder	(as	held	by	the	
Card Provider)
                                                                             IMPORTANT NOTES
Signature                               J TAN                                1 Please note that Debit Cards cannot be accepted for
                                                                               premium payments.
                                                                             2 Please note that some Credit Cards cannot be used outside
Date (ddmmyy)                   1 | 9        0 | 7       1 | 1                 their country of issue and therefore we strongly recommend
                                                                               that you contact your card issuer to ensure your card can be
                                                                               used in this instance.


*	I	understand	that	FPIL	will	complete	these	once	the	premium	amount	is	finalised




XSG4/AP 07.11                                                                                                                                       Page 23
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM




XSG4/AP 07.11                                                                 Page 24
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Notes




XSG4/AP 07.11                                                                 Page 25
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Notes




XSG4/AP 07.11                                                                 Page 26
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON PAYMENT OF A CLAIM
Notes




XSG4/AP 07.11                                                                 Page 27
Important Information
THE	INFORMATION	GIVEN	IN	THIS	DOCUMENT	is	based	on	current	Singapore	law	and	taxation	
practice, which may change in the future.
No	liability	can	be	accepted	for	any	personal	tax	consequences	of	this	scheme	or	for	the	effect	of	
future	tax	or	legislative	changes.
Should	Friends	Provident	International	Limited	(Singapore	Branch)	become	unable	to	meet	its	
liabilities	to	its	policyholders,	they	will	receive	the	protection	of	the	Life	Assurance	(Compensation	of	
Policyholders)	Regulations	1991	of	the	Isle	of	Man.
Should	you	wish	to	make	a	complaint,	please	write	to	our	Customer	Relations	Manager	at	Friends	
Provident	International	Limited	(Singapore	Branch),	,	63	Market	Street,	#06-05	Bank	of	Singapore	
Centre,	Singapore	048942.	Please	see	‘Your	guide	to	Life	Insurance’	for	further	details.
Complaints	we	cannot	settle	may	be	referred	to	the	Financial	Insurance	Disputes	Resolution	Centre	
Limited	(‘FIDReC’)	for	assistance	within	six	months	from	the	date	you	failed	to	reach	an	agreement	
with	Friends	Provident	International	Limited	(Singapore	Branch).	You	can	contact	FIDReC	at	112	
Robinson	Road,	#13-03	HB	Robinson,	Singapore	068902.	Tel:	63278878;	Fax:	6327	8488;
Website:	www.fidrec.com.sg;	Email:	info@fidrec.com.sg.
Some telephone communications with the Company are recorded and may be randomly monitored.
LEGAL	INTERPRETATION
Each	policy	is	governed	by	and	shall	be	construed	in	accordance	with	the	law	of	Singapore.




Friends Provident International Limited (Singapore Branch)
63 Market Street, #06-05, Bank of Singapore Centre, Singapore 048942
Telephone: +65 6327 4019 Fax: +65 6327 4020
Website: www.fpinternational.com/singapore
Registered in Singapore No. F06835G
Authorised by the Monetary Authority of Singapore to conduct life insurance business in Singapore.
Member of the Life Insurance Association of Singapore
Member of the Singapore Financial Dispute Resolution Scheme
Friends Provident International Limited
Registered & Head Office: Royal Court, Castletown, Isle of Man, British Isles, IM9 1RA
Telephone: +44 1624 821212 Fax: +44 1624 824405
Incorporated company limited by shares. Registered in the Isle of Man No. 11494
Authorised by the Isle of Man Insurance and Pensions Authority



XSG4/AP 07.11

				
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