SUPPLEMENTARY QUESTIONNAIRE FOR ALL RIDERS

APPLICABLE TO LADIES ONLY TO BE COMPLETED BY

LIFE TO BE ASSURED
Proposal No. New NRIC No.
- -
Policy No. Old NRIC/BC/Passport No.

IMPORTANT NOTICE:
In relation to insurance contracts wholly unrelated to your trade, business or profession
TAKE NOTE that you are under a duty to take reasonable care not to make any misrepresentation when:
(a) answering specific questions that are relevant to the decision of the insurer whether to accept the risk or not and the rates and terms to be
applied; and
(b) confirming or amending any matter previously disclosed by you in relation to your insurance contract.
Your duty of disclosure shall continue until the time the contract is entered into, varied or renewed.
In relation to insurance contracts related to your trade, business or profession
TAKE NOTE that you are under a duty to disclose to the insurer any matter that:
(a) you know to be relevant to the decision of the insurer on whether to accept the risk or not and the rates and terms to be applied; or
(b) a reasonable person in the circumstances could be expected to know to be relevant.
This duty of disclosure shall continue until the time the contract is entered into, varied or renewed.
If you do not understand your obligations as stated above, please seek clarification.
If you are in any doubt about whether certain facts are material, these facts should be disclosed.

Name of Life to be Assured:

Age:
We would appreciate if you could kindly complete this questionnaire.
(Put a ( ) in the appropriate box to indicate your answer wherever applicable.)
1. Have you ever had, or received any treatment for, or intend to be treated or consult a physician for:
(a) any disease or disorder of the breast including breast lump, cyst, fibroadenoma, fibrocystic disease, nipple changes or discharge, mastitis,
mammary dysplasia, Pagets disease of the nipple or breast, carcinoma in situ, cancer and growth? If Yes, please give details.
Yes No

(b) any disease or disorder of the cervix uteri, uterus or ovaries including ovarian cysts, abnormal uterine or vaginal bleeding, abnormal
enlargement of the abdomen, fibroid, polyp, carcinoma in situ, cancer and growth? If Yes, please give details.
Yes No

2. Have you undergone or been advised to have a pap smear, mammogram, biopsy or operation of the breast, ultrasound of the breasts or pelvis,
cone biopsy or colposcopy, or any other gynaecological investigations? If "Yes", please give details.
Yes No

3. Have you ever had any complications during pregnancy, such as ectopic pregnancy, pre-eclampsia, diabetes, hypertension or protein in urine?
If "Yes", please give details.
Yes No

4. Have your children ever suffered from disorder such as spina bifida, Down's Syndrome or any congenital heart disease?
If "Yes", please give details.
Yes No

It is hereby declared I have not withheld any material information that may influence the assessment or acceptance of the proposal. Without limiting
the generality of the foregoing, I hereby further declare that the answer(s) I have given above is/are true, complete and accurate.
I agree that this form will constitute the basis of my Proposal for Assurance and that failure to disclose any material fact known to me may invalidate
the contract.
Date / /
Day Month Year

Signature of Life to be Assured * Signature of Witness

Name in block letters Name in block letters

NRIC No.

* STATEMENT OF WITNESS Address

I hereby certify that the signature in this form was made before me and that to my own personal knowledge it is the signature of the Life to be
Assured under the Policy No. / Proposal No. as mentioned above.
NBZ-QSLR1-V06e-012015 FPMS

Great Eastern Life Assurance (Malaysia) Berhad (93745-A)

Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur Tel +603 4259 8888
4264113551
Fax +603 4259 8000 E-mail wecare-my@greateasternlife.com Website www.greateasternlife.com