Accident Insurance Registration Form

INSURANCE REGISTRATION
If you reside in National Capital Region (NCR) click here instead

If you reside in Negros kindly click here instead

Everyone else click NEXT below

REFERRAL
Did someone refer you?*

YesNo
If yes who referred you?
INSURANCE OPTIONS
CLICK HERE TO VIEW DETAILS ABOUT INSURANCE LEVELS
Which Level of protection are you applying for?
PAYMENT OPTIONS
Insurance Cost hidden
Insurance Cost
How will you pay*

G-Cash
G-CASH
HOW TO PAY THROUGH G-CASH

0908-715-2582

Mariejo Vifree Angeles
Upload a screenshot of your payment*

Browse Files
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PERSONAL DETAILS
Name*

First NameMiddle NameLast Name
Gender

MaleFemale
Civil Status*

SingleMarriedOther
Mobile #*
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date

INSURANCE INFORMATION
Name of employer*
Business Address*
Business Telephone No(s)*
Profession/Occupation*
Nature of Work*
Annual income in Pesos*
Beneficiary (ies)/Relationship*
Do you have any physical defect or infirmity of any kind or have you ever had diabetes, tuberculosis, varicose veins, disease of the heart or brain, amputation, impairment of hearing of sight or any nervousaffection?*

NoYes
Please give details*
During the last 5 years, have you been hospitalized or consulted a physician for any reason?*

NoYes
Please give details*
With what company (ies) and for what amounts are you presently insured?*

NoYes
Please give details*
Have you ever claimed or received compensation under any accident or sickness policy?*

NoYes
Please give details*
I hereby certify that all information given in this application are true and correct. I understand that non- disclosure and/or falsification of information herein required shall be grounds for the disapproval of my application, immediate termination of the insurance coverage and/or legal action against me.*

Conforme, I agree
Sign using your mouse or finger if you are using a smartphone/tablet*

Clear
NOTE: Under Republic Act 9160 (Anti-Money Laundering Act) as amended by Republic Act 9194 and pertinent regulations, all insurance companies are required to satisfactorily establish the identities of all its customers. Hence, Standard Insurance Co., Inc. reserves the right not to accept and process any application for insurance if the customer fails to provide sufficient evidence to establish his identity

EMERGENCY CONTACT INFORMATION
Name*

First NameMiddle NameLast Name
Mobile #
Relationship to you

SpouseParentChildFriendRelative
Should be Empty:

INSURANCE REGISTRATION

REFERRAL

INSURANCE OPTIONS

PAYMENT OPTIONS

G-CASH

PERSONAL DETAILS

INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION