Health Statement Form
Health Statement Form
Health Statement Form
Please fill in block letters and tick appropriate boxes and circles. Requests received by FWD service counters within the cut-off time of 2:00 PM will be processed
within the day. Requests received beyond cut-off time will be processed the next business day.
1. Personal Data of Policy Owner (Your personal information in our database shall be updated based on the details you provide below.)
2. Service Request/s
REINSTATEMENT (If for reinstatement, please provide additional information below.)
REMOVE / CHANGE RATING ADHOC TOP-UP
CHANGE PLAN TO INCREASE IN SUM ASSURED
ADD RIDER OTHER TRANSACTION
Permanent Address:
No. and Street Barangay/Subdivision
Business/Office Address
No. and Street Barangay/Subdivision
5. Data Protection
FWD has appointed a Data Protection Officer to handle any inquiries relating to your personal information. If you would like to obtain a copy of the FWD Life
Insurance Corporation Personal Data Policy and Practices, please write to the Corporate Data Protection Officer at 19/F, W Fifth Avenue Bldg., 5th Avenue
cor. 32nd Street, Bonifacio Global City, Taguig City 1634, Philippines.
6. Declaration
I UNDERSTAND AND CONFIRM THAT:
1. The information I have provided above and in any supporting documents and/or records (collectively defined as this 'Form') are true and complete and
shall form part and be the basis of the assessment of this request and approval. I understand that providing false, inaccurate or incomplete information
may result in my transaction request being denied and shall give FWD the right to cancel the Policy, repudiate the claim or forfeit all payments to be
made.
2. I authorize FWD and/or its duly authorized representative to secure whatever information and/or records from any employer, any physician,
hospital/clinic, other medically related facility, and any organization/institution or person, who has any records and/or knowledge with regard to my or
the Insured's Illness, sickness, condition, disability and/or injury as described in this Form.
3. I understand that my request (if applicable) for policy change, reinstatement, or addition of coverage/rider which requires evidence of insurability shall
not take effect unless duly approved by FWD and any required payment for the transaction request is paid in full. I further understand that the
Incontestability and Suicide Exlusion provisions in the Policy shall apply and the period stated thereunder shall run upon FWD's approval of the request
for reinstatement, increase or decrease of sum insured or rider.
4. I have fully disclosed all of my citizenships, tax status, residencies, relevant taxpayer identification numbers and agree to notify FWD within thirty (30)
days of any changes to the above information. For the purposes of ensuring continued compliance, FWD may request information and/or documents
from me including completed, executed and, if necessary, notarized tax declarations or forms.
5. I authorize FWD to disclose my personal and financial information to any government or tax authority (within or outside the Philippines) for the purposes
of ensuring FWD's continual compliance with applicable laws, regulations, guidelines and good market practices. I also agree that FWD has the right to
require any of my beneficiaries, claimants, assignees and/or payees to:
a. provide FWD with their respective personal and financial information;
b. sign and submit such documents as FWD may reasonably require; and
c. authorize FWD to disclose such personal and financial information to relevant Filipino and/or foreign government and/or tax authorities.
6. The amounts invested in my policies have been declared to the relevant government and tax authorities (within or outside the Philippines) and none were
derived, directly or indirectly, from illegal or unlawful activities and sources or from tax evasion. I authorize FWD to withhold payment of any amounts
due to myself, my beneficiaries, claimants, assignees and/or payees if required by any relevant government or tax authorities (within or outside the
Philippines).
m m d d y y y y
Place of signing Date: / /
Policy Owner's Signature over Printed Name Insured's Signature over Printed Name Irrevocable Beneficiary