Proposed Principal Insured:

Rosita Ramos - Age 60, Female

Policyowner or Payor:
Rosita Ramos

Dear Rosita,

Congratulations on taking a vital step to secure your health with AXA, global leader in insurance. AXA Philippines
is the formidable synergy between two financial giants --- the AXA Group and the Metrobank Group.

AXA Philippines is a complete financial solutions provider that can help Fail-Proof your Future in preparing for
expected and unexpected life events, namely, retirement, education, income protection and health.

We are happy to share with you the details for your chosen health solution. Global Health Access is a
comprehensive worldwide health plan which provides extensive medical coverage to ensure that you can access
the best healthcare anytime, here and abroad.

You have chosen the Gold Lite plan and below is a summary of your plan & the benefits^ that you will enjoy:

Plan Summary:
Area of Cover Worldwide excluding US
Overall Yearly Maximum Benefit Limit PHP 100,000,000
Coverage In-patient Only
Annual Deductible Nil
Outside Area of Cover Emergency treatment only and up to PHP 10,000,000

Benefits^:
Major Medical Care Emergency Care Value-added Benefits

· In-patient hospital charges and · Emergencies · Health at Hand

accommodations · International Emergency · 2nd Medical Opinion
o Including pre/post Medical Assistance
outpatient treatment · Road ambulance transport
· Special Out-patient conditions
o Dialysis
o Radiotherapy
o Chemotherapy

For a yearly maximum benefit of PHP 100,000,000, your Annual Premium will be PHP 96,000.00 . You can pay
semi-annually for only PHP 49,920.00.

^Benefits may be subject to limits, please refer to the appendix for your chosen plan’s inclusions/exclusions/ limits.

The succeeding pages of this proposal provide more details on the benefits and features of Global Health Access.

Again, thank you for your interest in Global Health Access. Should you need assistance or clarification, please call
me at the number specified below or call the AXA Customer Care Hotline at Tel. No. 5815-292 or 3231-292.

SHIELA TALAGTAG DELA PENA

43216
22078

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Version Number: 3.10.10
Plan Code: GHX 4
Global Health Access
for: Rosita Ramos, 60

Premium Breakdown:
Your initial annual premium.

Name Age Gender Annual Premium (1st Policy Year)

Rosita Ramos 60 ᵃ Female PHP 96,000.00
Date for Next Insurance Age: ᵃ5/12/2018

Upon renewal of your plan, your estimated renewal annual premiums for the next 3 policy years are as follows:
Name Annual Premium Annual Premium Annual Premium
Policy Year 2 Policy Year 3 Policy Year 4
Rosita Ramos PHP 99,840.00* PHP 106,560.00* PHP 112,320.00*

* Premiums will change according to the attained age on renewal. The premiums shown are those currently in effect,
but the premiums may change upon renewal of the plan and will depend on those in effect at the date of renewal.

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Global Health Access
for: Rosita Ramos, 60

BENEFITS TABLE
Gold Lite Plan
Area of cover Worldwide excluding US

Overall yearly maximum limit up to : PHP 100,000,000

Level of reimbursement Reasonable and customary (R&C) charges
Outside area of cover Emergency treatment only and up to
PHP 10,000,000
In-patient and daycare treatment
a) For in-patient treatment or day-care treatment in the
Philippines, it is a single room up to PHP7,500.00 per night.
Daily accommodation charges6
b) For in-patient treatment or day-care treatment outside the
Philippines, it is a standard single room.

Hospital charges6 Included

Organ Transplant6 Included
Reconstructive surgery6 Included
Surgical implants6 Included
Companion accommodation up to (per night)6 PHP 8,000
Cash benefit, per night6 PHP 10,000
In-patient treatment for AIDS/HIV6 (available after 5
consecutive years of membership on the same plan)
PHP 1,000,000 in an insured person's lifetime
Coverage will apply when signs or symptoms are present for
the first time after five years of continuous coverage under
the plan and any renewal thereof to an all-inclusive limit up
to
In-patient rehabilitation6 Included - up to 28 days3
Included - within 90 days prior to hospital admission and 90
Pre- and post-hospitalization Out-patient treatment6 days following discharge from hospital
Applicable in-patient direct billing network Global directory of hospitals
Out-patient treatment
Emergency Out-patient Treatment due to an accident Included
Radiotherapy and Chemotherapy6 Included
Kidney Dialysis Treatment6 Included
Surgical procedures received as an out-patient Included
Primary and Specialist Care
Only as part of ‘Pre- and Post-Hospitalization Out-patient
Diagnostic scans
Treatment’ Benefit
Physiotherapy, Occupational Therapy and Speech Therapy4 , 6
Other benefits
Hormone Replacement Therapy6 Included
Health screen/Executive Checkup up to PHP 12,000
Accidental damage to natural teeth Included
Oral and maxillofacial surgery6 Included
Local road ambulance transport6 Included
International Emergency Medical Assistance Included
Pre- and post-natal complications6 (available after 12
consecutive months of membership) Included
New Born Accommodation 6 Included
Psychiatric treatment up to6 PHP 400,000 (for In-Patient Treatment only)
Hospice and palliative care6 (available after 12 consecutive
months of membership) up to PHP 750,000 in an insured person's lifetime
Second Medical Opinion Included
Health at Hand Included
Notes:
1) The benefit limits are all in Philippine Pesos. Premium and eligible claims will be paid in Philippine Pesos unless a different
claims reimbursement currency is preferred by you or the insured person at the time of claim. If we could process the eligible
claims in your preferred claims reimbursement currency, please note that you or the insured person would have to bear all
bank/credit charges and foreign exchange losses (if applicable).
2) The benefit limits are per insured person each policy year unless otherwise specified and are reduced each time the insured
person claim only by the net amount (less any deductible or co-insurance) we have actually paid. Please refer to the policy on the
full terms and conditions applying to these benefits.
3) We will pay for in-patient rehabilitation when:
• it is carried out by a medical practitioner specializing in rehabilitation; and

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Plan Code: GHX 4
Global Health Access
for: Rosita Ramos, 60

• it is carried out in a rehabilitation hospital or unit which is recognized by us; and

• the treatment could not be carried out on an out-patient basis, and
• the costs have been agreed, in writing by us before the rehabilitation begins.
We will not pay for in-patient rehabilitation for more than twenty-eight (28) days except in cases such as in severe central nervous
system damage caused by external trauma. For cases such as in severe central nervous system damage by external trauma, we
will not pay for in-patient rehabilitation for more than one hundred eighty (180) days.
4) Subject to the limits applicable to the insured person’s plan, we will pay for treatment given by a physiotherapist, occupational
therapist or speech therapist, who is recognized by us and registered to practice where the eligible treatment is given.
Benefit is payable only following in-patient treatment for an eligible medical condition, provided that your insured person has
been covered under the policy since before the in-patient treatment commenced.
Treatment given by physiotherapist, occupational therapist or speech therapist must be under the medical supervision of a
medical practitioner. Medical supervision means that the reason for referral, where applicable, has been initiated by the medical
practitioner who has defined a diagnosis.
There must be a clear treatment plan from the physiotherapist, occupational therapist or speech therapist with an end point and
expected outcome.
5) If the policyholder has opted for annual deductible at the time of application (please refer to the policy specifications), the annual
deductible will apply to all eligible in-patient treatment and any benefit that is arising therefrom, or associated therewith to the in-
patient treatment. Please refer to item 6 for more details.
6) Annual Deductible is applicable to the following eligible in-patient treatment benefits and any benefit that is arising therefrom or
associated therewith to any eligible in-patient treatment:
l Daily accommodation charges l Radiotherapy and chemotherapy
l Hospital charges l Kidney Dialysis Treatment
l Organ Transplant l Physiotherapy, Occupational Therapy and Speech Therapy
l Reconstructive surgery l Hormone Replacement Therapy^
l Surgical implants l Oral and Maxillofacial surgery^
l Companion accommodation l Local Road ambulance transport
l Cash benefit l Pre and post-natal complications^
l In-patient treatment for AIDS/HIV l New born accommodation
l In-patient rehabilitation l Psychiatric treatment
l Pre- and post-hospitalization Out-patient treatment l Hospice and palliative care
^If there is no in-patient treatment, the annual deductible will not apply. If there is an eligible in-patient treatment, the annual
deductible will apply to the in-patient treatment and the associated benefits.
7) Pre-existing condition* exclusion/limitations do not apply to Health screen/Executive check-up benefit.
8) All new plans will have an applicable waiting period of 12 consecutive months for the following medical conditions and their
associated medical conditions:

1. Cancer 2. Hepatitis B 3. Hepatitis C

4. Diabetes 5. Heart Disease 6. Kidney Failure
7. High Blood Pressure 8. Chronic obstructive pulmonary disease 9. Liver cirrhosis
10. Stroke/Cerebrovascular accident 11. Transient ischaemic attack

9) There will be a waiting period of three (3) consecutive years for the reason/underlying cause for the hospitalization or surgery
and their associated medical conditions relating to the Question 3 of the underwriting questions of the application form.
*Pre-existing condition(s) - refers to any medical condition which during the two (2) years preceding the policy effective date, or
reinstatement date, or plan upgrade date, whichever date is later: (i) your insured person has been diagnosed; or, (ii) for which
your insured person has received medication, advice or treatment, or, (iii) which the policyholder and/or your insured person
should reasonably, based on our appointed independent medical practitioner’s opinion, have known about; or, (iv) for which your
insured person has experienced symptoms even if your insured person has not consulted a medical practitioner.
10) Premium rates of Global Health Access are not guaranteed. Subject to approval of the Insurance Commission, AXA Philippines
reserves the right to change all or any part of this policy that will be issued including the Benefits Table and/or any of the terms
and conditions.
11) Premium of Global Health Access will be adjusted based on the attained age of the insured on each policy anniversary and
according to the prevailing premium rates at the time of renewal. You may refer to your Financial Executive/Financial Advisor or
AXA for more information on renewal premium.

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Version Number: 3.10.10
Plan Code: GHX 4
Global Health Access
for: Rosita Ramos, 60

Exclusions and Limitations:

Listed below are some exclusions and limitations related to Global Health Access. This list is not exhaustive.
The complete list of Exclusions and Limitations is detailed in the policy contract that will be issued for this
product:
· Pre-existing condition as defined, including any treatment and complications arising from the pre-existing condition and its
associated medical conditions unless allowed for as per the terms and conditions;
· Any charges for treatment related to and/or of congenital conditions;
· Under the ‘Pre- and post- natal complications’ benefit, we will pay for treatment of a medical condition which is due to and occurs
during the pregnancy. However we will not pay for such treatment if the pregnancy was a result of assisted means or any form of
assisted conception/assisted pregnancy or elective/non-medically necessary caesarean section;
· Treatment begun, or for which the need had arisen, during the first ninety (90) days after birth for any child conceived by artificial
means or any form of assisted conception/assisted pregnancy;
· Treatment of, or related to, prematurity or any consequence of it;
· Foetal surgery. By this we mean treatment given or undertaken on a foetus while in the womb;
· Termination of pregnancy or any consequences of it, except where eligible under the ‘Pre- and post-natal complications’ benefit;
· Contraception, investigations into and treatment of infertility, treatment designed to increase fertility (including treatment to prevent
future miscarriage), investigation into miscarriage and assisted conception/assisted pregnancy, sterilisation (or its reversal) or any
consequence of any of them or of any treatment for them;
· Treatment of impotence or varicocele or any of their consequence;
· Treatment of, or related to, sexual dysfunction or any consequence of it;
· Treatment of sexually transmitted diseases;
· The costs of collecting donor organs or tissue or any administration costs (such as, but limited to, the cost of donor search) even if
such transplants are allowed by the terms of this policy;
· Treatment which arises from or is directly or indirectly caused by a self-inflicted injury or an attempt at suicide;
· Any treatment to correct refractive defects of the eyes such as long or short-sightedness or astigmatism, unless allowed for by the
insured person’s plan; laser/lasik eye surgery;
· Any additional hospital charges for a non-standard single room (for in-patient/day-care treatment outside the Philippines) or in a
single room that exceeds the limits stated in the benefits table applicable to the insured person’s plan (for in-patient/day-care
treatment in the Philippines), luxury menu items, menu items not included as standard, visitor’s meals;
· The costs of providing or fitting any external prosthesis or orthosis or appliance or medical aids or durable medical equipment;
· Orthodontics, periodontics, endodontics, preventative dentistry, and general dental care including fillings, no matter who gives the
treatment unless allowed for by your insured person’s plan stated in the benefits table;
· Dental implants;
· Claims if your insured person has travelled outside his/her area of cover to get treatment (whether or not that was the only reason)
or travelled against medical advice even if it is within the area of cover;
· Treatment incurred as a result of engaging in or training for any sport for which your insured person receives a salary or monetary
reimbursement, including grants or sponsorship (unless your insured person receives travel costs only);
· Treatment of injuries sustained from base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free
climbing, mountaineering with or without ropes, scuba diving to a depth of more than 10 meters, trekking to a height of over 2,500
meters, bungee jumping, canyoning, hang gliding, paragliding or microlighting, parachuting, potholing, skiing off piste or any other
winter sports activity carried out off piste;
· Any claim or part of a claim in respect of which you/your insured person have to pay an excess (or deductible or co-insurance). In
this case we will only pay the balance of the claim after we have deducted the excess (or deductible or co-insurance) amount; any
claim which is within the waiting period;
· Any charges made by medical practitioner, hospital, laboratory or any such medical services which are not reasonable and
customary;
· All bank or credit charges when the claims payment is made in a currency other than Philippine Pesos; foreign exchange losses;
· Nutritional supplements including but not limited to special infant formula and cosmetic products even if medically recommended
or prescribed or acknowledged as having therapeutic effects;
· Cryopreservation, or harvesting or storage of stem cells as a preventive measure against possible disease/illness/injury;
· Treatment which is not considered medically necessary or which may be considered as a matter of personal choice;
· In-patient treatment for a medical condition which can be properly treated as an out-patient;
· Standard toiletries such as, but not limited to, shampoos, soaps, toothpastes, mouthwash, lotions, moisturiser, cleansers, shower
gels, contraceptives, proprietary headache and cold cures, with or without prescriptions, nor do we pay for telephone calls.

This proposal is an illustration only of the key features of the recommended insurance plan. You should refer
to your Financial Executive/Financial Advisor or the Company for more information. If your application is
accepted, you will receive a policy contract which will include detailed terms, conditions and exclusions.

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Plan Code: GHX 4
Global Health Access
for: Rosita Ramos, 60

DECLARATIONS AND ACKNOWLEDGEMENTS

Declarations
1. I confirm having read and understood the information contained in the Benefits Table Section, Notes
Section and Exclusions and Limitations Section of this illustration.
2. It is my understanding that the total premium I am going to pay when I purchase this plan shall consist of
the Global Health Access premium shown above.
3. I confirm having read and understood the information in this illustration. My Financial Advisor/Financial
Executive fully explained to me the benefits, feature and, exclusions and limitations related to the Global
Health Access product.
Product Transparency Declaration
By signing off on the items listed below, I acknowledge that the same have been discussed with and
thoroughly explained to me.

· I understand that I am buying a health insurance product.

· I understand that certain conditions may not be payable under the plan, as illustrated in the Exclusions
and Limitations of this proposal and detailed in the Exclusions and Limitations section of the policy
contract. This includes conditions that will not be payable during the waiting periods for certain medical
conditions and their associated medical conditions.
· I agree to answer all underwriting questions in the application form truthfully and I understand that any
mis-statement of facts, whether by commission or by omission may be grounds for AXA, in its absolute and
sole discretion, to decline to pay any benefit under the policy and also, to void the policy.
· I understand that the premiums will change according to any of the insured persons’ attained ages on
renewal. The premiums shown in this proposal are those currently in effect, but the premiums may
change upon renewal of the plan and will depend on those in effect at the date of renewal.
· I understand that due to the nature of the product AXA has the right to change the premiums of the policy
at any policy anniversary.
· I also understand that AXA has the right to change all or any part of the policy to be issued from any policy
anniversary and that AXA can change all or any part of the policy including the benefits table or the policy
terms, but only for the reasons shown in the policy document, and the changes will only apply when the
policy is renewed unless AXA is obliged by law to apply any change with immediate effect.
CONFORME: These declarations and acknowledgements are made
with the knowledge of AXA representative whose
signature appears below:

Financial Advisor/Financial
Applicant/Policy Owner Date Date
Executive
Signature over Printed Name
Signature over Printed Name
General Disclaimer
All information and opinions provided are of a general nature and for information purposes only. The
information and any opinions herein are based upon sources believed to be reliable, and AXA Philippines, its
officers and directors make no representations or warranty, expressed or implied, with respect to the
correctness, completeness of the information and opinions in this document. Please carefully read the policy
and endorsements and consider the risks, charges and expenses before buying the policy. You should seek
professional advice from your financial, tax, accounting or legal consultant before buying the policy.
THIS FINANCIAL PRODUCT OF AXA PHILIPPINES IS NOT INSURED BY THE PHILIPPINE DEPOSIT
INSURANCE CORPORATION (PDIC) AND IS NOT GUARANTEED BY METROBANK OR PS BANK.

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Version Number: 3.10.10
Plan Code: GHX 4
 Reference Number: 22078-201802070133-2-01

FINANCIAL UNDERSTANDING SUMMARY

Dear ROSITA

Thank you for providing us with relevant information with regards to your financial needs.

Based on your current financial situation, which includes, among others, your personal
monthly gross income of 100,000.00, and after taking into consideration your objectives,
risk profile and priorities, you have selected Global Health Access Gold Lite Worldwide ex USA
for your Health need.

The details of your insurance coverage and your insurance premium are summarized in your
Global Health Access Gold Lite Worldwide ex USA sales illustration.

DELA PENA, SHIELA TALAGTAG

43216
22078

This document is not intended to be a part of your sales illustration of your application form. This is a
summary of the financial needs that you have provided during assessment by your distributor.