‘Transamerica Life (Bermuda) Ld. ‘ati
TRANSAMERICA aman Sa Application Supplement
LIFE BERMUDA LTD 1 Hiafayson Green Foreign Nationals &

Singapore 049246 i
Co. Reg. No. TOSFC6768E. For eign Travel

Proposed insured:
. NRIC/Passport No.: 3. Place of Birth:
. Nationality: 4b. Country of Citizenship:
Passport: Issuing Country, if different from nationality or citizenship.
Length of time with Present Employer.
Do you plan to reside in any country (outside of your primary residence) or travel to any country other than one of the following:
Australia, Canada, Hong Kong, Japan, New Zealand, Singapore, United States, Western Europe, or Taiwan for business
and/or leisure? Yes No If “Yes”, please provide details.

Destination(s) Date(s) | Frequency of} Duration of Purpose
(city, country) visit(s) visit(s) of visit(s)

During the past
12 months

Within the next
12 months

13 to 24 months
from now

8. Do you anticipate the pattern or frequency of the above-documented travel to change in the next 5 years? L} Yes LJNo
If “Yes”, please provide details.

It is represented that the statements and answers given in this Supplement to the Application are true, complete and correctly
recorded to the best of my knowledge and belief. It is agreed that this Supplement shall be a part of the Application to the
Company for insurance on the life of the Proposed Insured.

Signed at

City, Country Date (mmédd/yyyy)

x

Signature of Proposed Insured Witness to Signature of Proposed Insured

AGREEMENT OF PROPOSED OWNER IF OTHER THAN PROPOSED INSURED

The Proposed Owner agrees to be bound by all statements, answers, and agreements made by the Proposed Insured in this
Supplement to the Application. If the Proposed Owner is a corporation, an authorized officer, other than the Proposed Insured
must sign as Proposed Owner, give full corporate title and name of corporation with the company stamp below.

Signed at on
City, Country Date (mmédd/yyyy)

Xx

Signature of Proposed Owner Witness to Signature of Proposed Owner

00000

Corporate Title: Corporation Name:

MPQ 168G-0109