‘Transamerica Life (Bermuda) Ltd. i j
TRANSAMERICA —__ Sinstporench Of Application Part 2
LIFE BERMUDA LTD 1 Eintayson Green Non-Medical Health History
Singapore 049246
Co. Reg. No. TOSFC6768E

Complete a separate Part 2 for each person applying for coverage. Policy No.

1. PROPOSED INSURED’S NAME: (Surname, Given Name) | DATE OF BIRTH NRIC/PASSPORT NO.: |

2. NAME AND ADDRESS OF YOUR 3. DATE AND REASON LAST CONSULTED:
PERSONAL PHYSICIAN:

4. CURRENT MEDICATION OR TREATMENT:

5. HEIGHT: WEIGHT: Has your weight changed more than 15 pounds in the past year?
lf “Yes”, reason:

For all “Yes” answers, provide full details on Page 2.

6. WITHIN THE PAST FIVE YEARS HAVE YOU:

a. Consulted, been examined or been treated by any physician or practitioner?
. Had an X-ray, electrocardiogram or any laboratory test or other diagnostic study?

. Used nicotine in any form? (indicate type, frequency and date last used on Page 2)... .

. HAVE YOU EVER HAD, BEEN TOLD BY A MEMBER OF THE MEDICAL
PROFESSION THAT YOU HAVE, OR BEEN DIAGNOSED WITH OR TREATED FOR:

. Seizure, fainting, stroke, loss of consciousness, tremor, paralysis, or any disease or

. High blood pressure, heart attack, heart murmur or palpitation, or anemia or any
disease or abnormality of the heart, blood vessels or blood?

. Asthma, pneumonia, emphysema, tuberculosis, or any disease or abnormality of the
lungs, bronchial tubes, or respiratory system?

. Ulcer, colitis, hepatitis, cirrhosis, or any disease or abnormality of the esophagus,
stomach, intestines, rectum, gallbladder or liver?

. Sugar, protein, or blood in urine, sexually transmitted disease, stone or any disease or

Immunodeficiency Virus (HIV) infection, or tested positive on an AIDS/HIV-related test?

MPN 15G-0109 NON-MEDICAL Page 1 of 2
Application Part 2 (Continued) Application Part 2

8. WITHIN THE PAST TEN YEARS, HAVE YOU USED:
a. Amphetamines, barbiturates, sedatives or morphine or any other narcotic drug except

b. Cocaine/crack, methamphetamine, Ecstasy (MDMA), heroin, marijuana, PCP, LSD, or
any other hallucinogenic drug?

9. OTHER:
. Have your parents, brothers, sisters or grandparents ever had cancer, diabetes, heart
disease, mental illness or attempted suicide?
. Have you ever been treated or counseled for the use of alcohol or drugs or joined an
organization for your alcohol or drug dependence or abyse?
. Has any application for insurance on your life ever been declined, withdrawn, postponed,

Give complete details of all “Yes" answers to questions 6-9, including all dates, diagnoses, duration,
outcome, treatments and medications prescribed and the names and addresses of all hospitals and
attending physicians or counselors. If additional space is required, attach sheet of paper, signed, dated

and witnessed.

10. FAMILY HISTORY: Show age and present health, or if deceased, show age at death and cause of death.

Ages Present Health Cause of Death Ages Present Health Cause of Death
Brothers

Father

Mother Sisters |

It is represented that the statements and answers given above are true, complete, and correctly recorded. To the extent
allowed by law, | waive my rights to prevent disclosure of any knowledge or information about the above questions. This
waiver applies to any physician, hospital, official or employee, or other person who has attended or examined me, or who
has been consulted by me. | authorize such person(s) to make such disclosures. Such person(s) may also testify to their
knowledge. This authorization is made on behalf of myself and any person who shall have or claim any interest in any
contract of insurance issued on this Application.

Signed at

City, Country Date (mmidd/yyyy)

CERTIFICATION: | certify that | have truly and accurately
recorded on this form the information supplied by the

Proposed Insured.
xX
x Signature of Proposed Insured (of parent or legal
Signature of Witness/Solicitor guardian if Proposed insured is a minor)

INN

MPN 1SG-0109 NON-MEDICAL Page 2 of 2