DECLARATION OF INSURABILITY

Gormonwealth Life f
a?
This forms part of the Application under Policy No. ..................

Name of the lnsured (Print name in full with surname first) Heighl Weighl
(ftlcm) (lblks)
Mr/ Mrs/ l\,4iss

Gain/(Loss) in weight in past year (lblkq) ..............

1. (a) Are you suffering from any disease or symptoms of disease? (c)

(b) Name and address ;;r":;;;,;;;;,." (d) What treatment was given or medication prescribed?
"t;,":;; ",",",

Yes No Give details of all "Yes answers

2, Wlihin the past 5 years, have you :
(a) Consulted, been examined or been treated by any physician and practitioner?
(b) Had an X-ray, Electrocardiogram or any laboratory test or study?
EE including all dates, diagnoses, medication,
durations, outcome with names and
(c) Had an observation or treatment at a clinic. hospital or sanitarium?
(d) Been advised to have any diagnostic test, hospitalization or surgery of which you have not
E addresses of ail hospitals and attending
physicians.
u ndertaken? t_l lf additional space required, attach sheet
paper, sr9r
3. To the best ot your knowledge, have you ever had any disturbances of or been treated on
the followings :

(a) The Heart, Blood Vessels, such as : -

(i) Rheumatic fever, murmur, shortness of breath, swelling of ankles, irregular pulse?
(ii) Leg cramps, phlebitis, varicose veins, poor circulation?
(iii) Chest discomfort, angina or heart disease?
(iv) Have you had high blood pressure?
(b) The Nose, Throat, Lungs, such as: -
Asthma, tuberculosis, chronlc bronchitis, blood spitting, pleurisy, emphysema, tumor?
{c) The Abdominal Organs, such as : -
Hernia, ulcer, colitis, bleeding, diverliculitis, gallstones jaundrce. liver disease. tumor?
(d) The Kidneys, Bladder, Genital Organs, such as : -
lnflammation, stone, tumor, venereal disease, sugar/albumrn/blood/pus in the urine?
(e) The Nervous System, Eyes, Ears, such as: -
Convulsions, stroke, seizures, nervous breakdown, tumor or impairment of sight or hearing?
(fl The Glandular System, Blood, such as : -
Goitre, anemia, diabetes, gout, enlarged glands, drsorder of breasts, tumor, skin conditlon or
allerqy?
(g) The Musculo-Skeletal System, such as : -
Any injury or disorder of the muscles. bones. joints or spine?
Amputation, paralysis, deformity or tumor?
(h) Cancer or cyst of any kind?
(i) The AIDS (Acquired lmmune Deficiency Syndrome), such as : -
(i) Aids or the Aids Related Complex (ARC)?
(ii) Any positive blood test for antibodies to the Aids virus?
{iii) Any of the followrng syrnptoms in the past 3 months for more than one week continuously.
fatigue, weight loss, diarrhea, enlarged lymph nodes or unusual skin lesions?
0 Excessive use of alcohol, tobacco, or any habit formlng drug?
(k) Any other disease, illness, injury not stated above?
Give Detarls of Preseni Health
4. Family History Age Any Heart Disease, Diabetes? Age Cause of Death 5. Have you smoked in the past 12 months? Yes l-__l No [---l
Father
lf Yes,
Mother
(a) State type and quantity per day .............

L (b) Have you been advised by Doctor to stop smoking?

Brothers i D
e
and i a
Yes f__l No f__l
n d
Sisters
s

I declare that all the foregoing statements and ans\iver are full, complete and true and shall form part of my application for insurance of PT Commonwealth Life
I further authorize any physician, hospital, clinic, insurance company or other organization or person that has any records or knowledge of me or my health to
disclose to PT Commonwealth Lile or its representative. A photostatic copy of this application shall be as the original.
Date Signed (D/M,^/) At (Citv) Signature of the Proposes lnsured
a

Signature of Witness/Medical Examiner

d
PTCommonwealthLife,WismaMetropolitan!l SthFloor,Jl.Jend.SudirmanKav.29-31,JakarIa1292O,lndonesia Telp.(021)5705000,2929S500 Fax.(021)5205353
Pusat Layanan Nasabah (onmCenter 5oo 525 www.commlife.co.id
MEDICAL EX.AMINER'S REPORT
Gonmonwealth Life
'-.rrf
Examination to be made in private andrthis form
to be compleled in examiner's own handwriting

Name of the lnsured (Print name in full with surname first) Agent's name and code

Height Weight unest unesr Abdomen, at Amount of lnsurance Applied For

(ftlcm) llblko) (Full lnspiration) (Forced Expiratron Umbilicus (ft/cm) (Currency and amount)

'1. BLOOD PRESSURE Systolic 3. URINALYSIS

Diastolic Amounr of sugar ................
Before Exercise I After Exercise 5 Minutes Later Amounr of albumin ............
PH ....................
2, PULSE RATE
lrregularities per m'nute Other abnormalities noted

4. After careful inquiry and physical examination, do you find any evidence of past or present Yes No Please provide full details of adverse
diseases or disorders of the : findings and opinions for all "Yes" answer.
(a) BRAIN, NERVOUS SYSTEM? flest reflexes and co-ordination) EN
(b) EARS. NOSE. EYES. THROAT TEETH OT GUMS? E
-
(lf vision or hearing markedly impaired. indicate degree and correction)
(c) ENDOCRINE SYSTEM including THYROID, LYMPH and BREASTS? EN
(d) HEART. BLOOD VESSELS including varicose veins?
For heart disorder, please specify :

irregularity : Enlargement
' lvlurmur t-l
Dyspnea
Edema
Others, give details ..

For reart murmur. please also indicate :

1) TrN4rNG 2) INTENSITY 3) QUALITY

f-_l Systolic L I Fatnt [_-l sott
[__l Presystolic ]-_-.l Moderate [__--l Blowino
l__l Diastolic -__l Loud [--l Rough
4) ls ihe murmur constani or inconstant? I I Constant lnconstant
5) On exercise, does the murmur
[-_l lntensify? E Decrease? [-_l Disappear?
6; Location of murmur i

Apex by X
Area of murmur by outline ) r
Point of greatest intensity O
Transmission

7) Your comment of the murmur

(e) LUNGS?
(0 STOMACH, ABDOMEN (including scars) or ABDOMINAL ORGANS?
(s) GENITO - URINARY SYSTEMS? Et_f
(h) MUSCULOSKELETAL (including spine. joints. amputations. deformities)? E
(i) SKIN? [ft:]
5. Are there any hernias? n
6. Doyouhaveanyreasontosuspectanythingunfavourableabouthabitsinregardtodrugsoralcohol? [ft:]
7. ls appearance unhealthy and older than stated age?
L Are you aware of any additional medical history?

9. Are you sending any specimen or other laboratory or clinical reports to the Underwriting Department of PT Commonwealth Life
F_l voc f I Nl^ lf Yac nlaaca qnacifv

AM/PM on (D/M/Y)

Medical Examiner s name and address tq

PT Commonwealth Life, Wisma Metropoliian ll 8th Floor, J L Jend- Sudirman Kav- 29 - 31 , Jakarta 12920, lndonesia Telp. (021) 570 5000, 2929 9500 Fax. (021) 520 5353
Pusat Layanan Nasabah (onmCenter 5oo 525 www.commlife.co.id