Change Form (With Health Declaration) - AIA Singapore

D. Change Plan/Area of CoverChange the basic plan of the above policy(ies) to as follows:New Basic Plan - Please write in full New Sum Assured ($)With this change, the supplementary benefit(s) to be changed as follows:New Supplementary Benefit(s) - Please write in full New Sum Assured ($)Change the area of cover of the above policy(ies) to as follows:New Area of CoverNote: Change of Area of Cover can only be done on the policy anniversary date.E. Add Dependant(s)Add Dependant to the following plan/(s): (Please state the HS/HB Benefit Amount &/or A&H Plan Name)HSHBParticulars of DependantsName of Dependant 1Relationship to InsuredDate of Birth (DD/MM/YYYY)NRIC/Passport/FIN No.MaleFemaleMarital StatusCountry of ResidenceSingle Married Widowed/Divorced/ SeparatedResidency StatusCitizenship (if not Singaporean)Singapore Singapore PR Pass Holder OthersName of Dependant 2Relationship to InsuredDate of Birth (DD/MM/YYYY)NRIC/Passport/FIN No.MaleFemaleMarital StatusCountry of ResidenceSingle Married Widowed/Divorced/ SeparatedResidency StatusCitizenship (if not Singaporean)Singapore Singapore PR Pass Holder OthersPage 2 of 6

F. Change of Payor for Juvenile PolicyDetails of New Payor NameNRIC/Passport/FIN No.Date of Birth (DD/MM/YYYY)MaleFemaleMarital StatusSingle Married Widowed/Divorced/ SeparatedRelationship to InsuredOccupationExact DutiesCompany NameNature of BusinessBusiness AddressPlease tick Declaration A or BDeclaration A (if PB/PBC is applied, Part II Health Declaration must also be completed)I, the existing Payor hereby1. declare that the Payor/Owner of the policy be changed to the new Payor as named above.2. relinquish and transfer my right to exercise all privileges, rights and options provided under this policy to the new named Payor subject tothe terms and conditions contained in the policy and the Juvenile Endorsement attached.3. delete the Payor Benefit/Payor Benefit Comprehensive coverage under this policy.New Payor would like to apply for Payor Benefit (PB) Payor Benefit Comprehensive (PBC)Name of New Contingent OwnerNRIC/Passport/FIN No.Relationship of Contingent Owner to InsuredDeclaration B (applicable where the existing Payor has passed away.)I, the new Payor hereby declare that:1. the existing Payor had passed away.2. as I am the contingent beneficiary as stated in the application for assurance, I will be the new Payor of the policy. I shall pay the futurepremiums of this policy as and when they fall due.3. I wish to appoint Estate as the new contingent beneficiary.Please submit photocopy of Death Certificate.A. Details of Insured/Dependant and Policy OwnerPart II: Health DeclarationInsured/DependantPolicy Owner (applicable for PB/PBC)OccupationMonthly Income(Applicable for AIA Premium DisabilityCover)Exact DutiesNature of BusinessBusiness Address*GC00313030606*Page 3 of 6

If your answer to any of the questions below underRemarks.b. Have you had, been told to have, been treated for or suffered from symptoms of any of thefollowing.ApplicantOwner/Payor(applicable forInsured/Dependant PB/PBC)Yes No Yes Noi. Stroke, high blood pressure, chest discomfort, heart murmur or any heart related disorder?ii. Pneumonia, asthma, chest or breathing complaints, tuberculosis or any other lung disorder?iii. Breast lumps or any other disorder of the breasts?iv. Diabetes, raised cholesterol, liver disease, Hepatitis B or any form of hepatitis?v. Kidney disease, blood, protein or sugar in urine or blood in stools?vi. Cancer, tumour or growths of any kind, AIDS, HIV infection or sexually transmitted disease?vii. Fits, mental disorder or any other disorders or physical disabilities/defects, impairments,deformities, and/or any conditions affecting mobility, sight and/or hearing not mentionedabove?12. Have either of your natural parents or any siblings died or suffered from cancer, heart disease,stroke, high blood pressure, diabetes, kidney disease, mental disorder, or any hereditary diseasebefore the age of 60?Please provide details.Illness Age at Onset Current AgeAge at Death(if deceased)Relationship toInsuredRelationship toPayorRemarksAcknowledgement of Receipt of Product Summary1. I acknowledge receipt of all pages of this Product Summary and that I have read and understood its contents.2. I understand that any non-guaranteed benefits, including where applicable, any bonuses or Annual Dividends, assumed in the Product Summaryare subject to change and are not guaranteed.3. I understand that this Product Summary does not form a part of any contract of insurance. It is only a simplified description of the product featuresand general exclusions and is not exhaustive.4. I understand that it is the precise terms and conditions as appear in the policy contract which will bind the parties.Page 5 of 6