LIFE INSURANCE          SURVEY- APPLICATION FORM

   PERSONAL INFORMATION ABOUT THE INSURED

   APPLICANT / POLICY HOLDER                      (the information with * is required)

NAME * / SURNAME *

DATE OF  BIRTH *

ADDRESS *

  POSTCODE * /  CITY *

 REGION *

  TELEPHONE *

EMAIL ADDRESS

   INFORMATION ABOUT OTHER PEOPLE INSURED TO BE INCLUDED IN THE POLICY

 RELATIONSHIP

NAME  / SURNAME

 DATE OF BIRTH

HEALTH SURVEY

 RESPECTO DE TODOS LOS ASEGURADOS

  ANSWER TO THE FOLLOWING QUESTIONS

Have you undergone surgery?

-- YES NO

Have you planned any?

-- YES NO

Have you been under observation or in treatment in any hospital?

-- YES NO

Have you consulted or have you been under medical treatment this last year because of any symptom or transitory illness or defect?

-- YES NO

Have you got any transitory illness, chronic illness or defect now?

-- YES NO

Is any of the applicants got pregnant?

-- YES NO

  STATEMENT

Do you declare that all the answers given in this application form are true?  --- YES