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Supplementary Questions concerning

Asthma, Bronchitis or other Pulmonary Symptoms


Please PRINT clearly. In this form, you and your refer to the person being insured, while we, us, our and the Company refer to
Use BLACK ink. Sun Life of Canada (Philippines), Inc., a member of the Sun Life Financial group of companies.

1 General Information
Information about the person being insured
Name (Last, First, Middle)

Policy No. Client No. New Business Office

2 Questions
The person being insured must answer the following questions. Please indicate details for each question on the space provided.

1. Briefly indicate the symptoms you


experienced in your last 3 attacks. (e.g.,
cough, sputum production, wheezing
respiration, shortness of breath) and the
approximate date of onset.

2. Do you have shortness of breath? Yes No


If Yes, describe the degree (e.g., occuring on
ordinary activity or unaccustomed activity?)

3. a) Do you cough
a.1. only with colds Yes No
a.2. in the morning Yes No
a.3. chronic daily cough Yes No
b) If cough is productive of sputum, describe
in details. (e.g., amount, color, any blood?)
4. a) Do you suffer from attacks of asthma or
wheezing? Yes No
If yes, how frequent are these attacks?
If yes, when was your last attack?
b) Do the asthma attacks occur year-round Yes No
or seasonally?
5. Do you regularly take any treatment or
medication? Yes No
If Yes, describe.

6. Have you undergone any special tests (other


than routine chest x-rays) to investigate your
lung condition? Yes No
If Yes, give details, dates, results.
7. State the name and address of your doctor and date last consulted.

3 Signatures
This section must be You hereby agree that this forms part of your application for insurance on your life.
signed by the person Place of Signing Date of Signing (day/month/year)
being insured and, the
parent, if applicable.
Signature of person being insured if age is 16 & over Printed Name
X
Signature of parent if proposed insured is below 18 years old Printed Name
0ABPQ-2-06 X
PlPlease submit in 2 copies
*0ABPQ-2-06*