St. Peter Life Plans Application Form
Client Data Entry and Assessment Form for application as Plan holder. Kindly fill-out the form with your personal details to proceed with the processing of your official Life Plan Agreement (LPA) Contract.
Complete Name
*
First Name
Middle Name
Last Name
Suffix
Age (Years/Months/Days)
*
Date of Birth (Month/Day/Year)
*
Gender at Birth
*
Please Select
Male
Female
Place of Birth
*
Civil Status
*
Single
Married
Widow / Widower
Legally Separated / Divorced
Address
*
Nationality
*
Height / Weight
*
E-mail
*
example@gmail.com
Please select your Plan
*
St. Anne / Php 120,000
St. Bernadette / Php 100,000
St. Claire / Php 80,000
St. Dominique / Php 60,000
St. Gregory / Php 47,400
St. George / Php 43,400
Payment Mode
*
Spot Cash (with 10% discount)
Annual
Semi-Annual
Quarterly
Monthly
Facebook Account
*
Occupation
*
Company Name
*
Put N/A if unemployed.
Phone Number
*
Please input an active phone number.
Beneficiary No. 1 *Full Name *Age *Relationship to Planholder *Complete Address
*
Beneficiary No. 2 *Full Name *Age *Relationship to Planholder *Complete Address
Beneficiary No. 3 *Full Name *Age *Relationship to Planholder *Complete Address
By submitting this form, you hereby signify your agreement to get a St. Peter Life Plan.
*
YES
NO
Submit Form
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