‘Transamerica Life (Bermuda) Led. Application

i TRANS AMERIC A apore Branch Office

_ LIFE BERMUDA LTD | Finkayson Green Amendment

Singapore 049246
Co. Reg. No. TOSFC6768E

Life Insured:

The Application for Policy No. is amended as follows:

| represent, to the best of my knowledge and belief, that since the date of the Application for the policy no person
to be covered by the policy has, except as stated below,

Had a change in health due to injury or sickness; or

Consulted, been examined or been treated by any physician or practitioner; or

Changed occupation, aviation or military status; or

Had any life or accident and sickness, or medical service benefits declined, modified, canceled, or been
refused issue, renewal or reinstatement of such insurance or benefits; or

5. Applied for issuance or reinstatement of any insurance providing income during disability or providing
hospital or medical expense benefits.

PwON>

The only exceptions are: (State “none” if there are no exceptions)

| declare that | have, in an identical manner, completed and signed this Amendment that is attached to
and made part of the policy issued by the Company.

It is agreed that this Amendment shall be part of the Application for the policy.

Signed at on
City, Country Date (mm/dd/yyyy)

Signature of Proposed Insured (or parent or Witness to Signature of Proposed Insured
guardian if Proposed Insured is a minor)

Signature of Proposed Owner (if other than Proposed [nsured) Witness to Signature of Proposed Owner

APE 30SG-0109 *DTO14 *

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