BENLIFE REGULAR / INDIVIDUAL ACCOUNT FORM MVP/PL LIBI

PRODUCT NAME / PLAN

Please answer completely and accurately. Put “N/A” if question is not applicable. .

If PROPOSED INSURED is OWNER / PAYOR

If PROPOSED INSURED is MINOR

I. PERSONAL INFORMATION .

Proposed Insured Information.

Full Name

First NameMiddle NameLast Name

Date of Birth

Sex

Civil Status

Country of Birth

Please type what country if you select other

City / Municipality of Birth

Nationality / Citizenship

For Philippine Nationals, please provide National ID or SSS or GSIS or UMID ID & Tax Identification Number

SSS / GSIS / UMID or any Government Issued ID

Tax Identification Number

Please put N/A if Not Applicable

- - - - - AT LEAST 2 LEGAL ID's REQUIRED - - - - -

SSS / GSIS / UMID or any Government Issued ID

Browse Files

MULTIPLE ID's CAN BE ATTACHED HERE

Tax Identification Number ID

Browse Files

Please attached any Legal Identification if Proposed Insured is MINOR

Browse Files

For Foreign Nationals (Put N/A if not applicable)

ACR Number orSIRV / SRRV

Expiry Date

Date

ACR ID or SIRV/SRRV ID

Browse Files

Please limit attachment to 2mb only

Proposed Insured Contact Information.

Mobile Number

Telephone Number

Put N/A if not applicable

Email Address

I want to receive notices and marketing messages via

Permanent Address

Floor/No., Building / Street

Building/Street, Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Business Address (Put N/A if not applicable)

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Proposed Insured Other Information.

Occupation (Job Title & Functions)

Tenure

Rows	Years	Months

Employer / Business Name

Nature of Business / Industry

Other Occupation/s

Please put N/A if Not Applicable

Estimated Annual Income

Sources of Funds

Remittances (Country)

Other

Owner / Payor.

Full Name

First NameMiddle NameLast Name

Date of Birth

Sex

Civil Status

Country of Birth

Please type what country if you select other

City / Municipality of Birth

Nationality / Citizenship

For Philippine Nationals, please provide National ID or SSS or GSIS or UMID ID & Tax Identification Number

SSS / GSIS / UMID or any Government Issued ID

Tax Identification Number

Please put N/A if Not Applicable

SSS / GSIS / UMID or any Government Issued ID

Browse Files

Please limit attachment to 2mb only

Tax Identification Number ID

Browse Files

Please limit attachment to 2mb only

For Foreign Nationals

ACR Number orSIRV / SRRV

Expiry Date

Date

ACR ID or SIRV/SRRV ID

Browse Files

Please limit attachment to 2mb only

Owner / Payor Contact Information.

Mobile Number

Telephone Number

Put N/A if not applicable

Email Address

I want to receive notices and marketing messages via

Permanent Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Business Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Owner / Payor Other Information.

Occupation (Job Title & Functions)

Tenure

Rows	Years	Months

Employer / Business Name

Nature of Business / Industry

Other Occupation/s

Please put N/A if Not Applicable

Estimated Annual Income

Sources of Funds

Remittances (Country)

Other

Proposed Insured / Owner Payor Information.

Have you or any of your immediate family members or close relationships and associates been entrusted with prominent public position/s in (i) the Philippines with substantial authority over policy, operations, or the use or allocation of government-owned resources; (ii) a foreign State; or (iii) an international organization?

Rows	YES	NO
Proposed Insured
Owner / Payor

Are you a US citizen, resident, or a resident alien (US Green card holder)?

Rows	YES	NO
Proposed Insured
Owner / Payor

Do you have a United States Taxpayer Identification Number (SSN/TIN), address, telephone number? Or was the Owner born in the US?

Rows	YES	NO
Proposed Insured
Owner / Payor

BENEFICIARY INFORMATION.

Beneficiary 1 Full Name

Surname, Given Name, Middle Name

Relationship to the Insured

% of Share

Type of Beneficiary

Beneficiary Designation

Date of Birth (mm/dd/yyy)

Place of Birth

Gender

Nationality

Beneficiary 1 Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Click the BOX for additional Beneficiary.

Beneficiary 2 Full Name

Surname, Given Name, Middle Name

Relationship to the Insured

% of Share

Type of Beneficiary

Beneficiary Designation

Date of Birth (mm/dd/yyy)

Place of Birth

Gender

Nationality

Beneficiary 2 Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Click the BOX for additional Beneficiary.

Beneficiary 3 Full Name

Surname, Given Name, Middle Name

Relationship to the Insured

% of Share

Type of Beneficiary

Beneficiary Designation

Date of Birth (mm/dd/yyy)

Place of Birth

Gender

Nationality

Beneficiary 3 Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Click the BOX for additional Beneficiary.

Beneficiary 4 Full Name

Surname, Given Name, Middle Name

Relationship to the Insured

% of Share

Type of Beneficiary

Beneficiary Designation

Date of Birth (mm/dd/yyy)

Place of Birth

Gender

Nationality

Beneficiary 4 Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Click the BOX for additional Beneficiary.

Beneficiary 5 Full Name

Surname, Given Name, Middle Name

Relationship to the Insured

% of Share

Type of Beneficiary

Beneficiary Designation

Date of Birth (mm/dd/yyy)

Place of Birth

Gender

Nationality

Beneficiary 5 Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Click the BOX for additional Beneficiary.

Beneficiary 6 Full Name

Surname, Given Name, Middle Name

Relationship to the Insured

% of Share

Type of Beneficiary

Beneficiary Designation

Date of Birth (mm/dd/yyy)

Place of Birth

Gender

Nationality

Beneficiary 6 Address

Floor/No., Building / Street

Subdivision/Village/Barangay

City / MunicipalityProvince

Zip Code

Trustee Information.

(if any of the beneficiary/ies are minors)

Last Name, First Name, Middle Name

Date of Birth

(mm/dd/yy)

The Trustee is the Minor Beneficiary’s (state relationship)

Beneficial Owner Information.

Beneficial Owner refers to any natural person or entity who funds, owns or controls the customer/account, and/or on whose behalf a transaction or activity is being conducted, or has ultimate effective control over a legal person or arrangement. In relation to an entity, Beneficial Owner(s) are individual either owning or controlling more than 25% of the company’s shares or voting rights.

Rows	Yes	No
Does this policy have a Beneficial Owner? If Yes, please submit Beneficial Owner Form

II. PLAN INFORMATION .

Plan Details.

Plan (Product Name)

Please select one

Amount of Coverage (Sum Insured)

Amount of Coverage (Sum Insured) hidden

Effective Date

Date

Mode of Payment

Additional Benefits/Riders.

Premium Default Options.

III. MEDICAL INFORMATION .

(In this section, “you” and “your” refer to the life to be insured or applicant. If the life to be insured is below 18 years old, the questions must be answered by aparent or by a person who has full knowledge of the medical history of the life to be insured. If more space is required, use supplemental application form.)

A. Family History.

1. Have any of your biological parents or siblings been diagnosed before age 65 with heart disease, stroke, Transient Ischemic Attack (TIA) cancer, diabetes, or Parkinson’s disease/s?

Rows	Yes	No
Proposed Insured
Owner / Payor

2. Have any of your biological parents or siblings ever been diagnosed with polycystic kidney disease (PKD), Huntington’s disease, multiple sclerosis (MS),muscular dystrophy, Alzheimer’s disease, amyotrophic lateral sclerosis (also called ALS or Lou Gehrig’s disease) or any other motor neurondisease or disorder, retinitis pigmentosa or any other hereditary disease or disorder?

Rows	Yes	No
Proposed Insured
Owner / Payor

B. Height and Weight.

INSURED (Please browse to the right to fill out all the details) ------->

Rows	Height in ft.	Inches or	Cm.	Weight lbs. or	kgs.
Proposed Insured

INSURED

Rows	Yes	If Yes, provide details below	No
Proposed Insured

OWNER (Please browse to the right to fill out all the details) ------->

Rows	Height in ft.	Inches or	Cm.	Weight lbs. or	kgs.
Proposed Owner

OWNER

Rows	Yes	If Yes, provide details below	No
Proposed Owner

C. Personal History If you answered "yes" to any of the questions below, provide details on the next page.

Heart and Circulatory System 1. Have you ever been treated for or had any symptom or indication of aneurysm, angina, blood clot, chest pain, coronary artery disease (CAD), heart murmur, heart attack, high blood pressure, irregular pulse, peripheral vascular disease (poor circulation), stroke or cerebrovascular accident (CVA), transient ischemic attack (TIA) or any other disease or disorder of the heart or blood vessels?

Rows	Yes	No
Proposed Insured
Owner / Payor

Abnormal Growth and Malignancy 2. Have you ever been treated for or had any symptom or indication of cancer, tumor, cyst, leukemia, lymphoma, polyp or any other growth or malignancy?

Rows	Yes	No
Proposed Insured
Owner / Payor

Glands and/or Endocrine System 3. Have you ever been treated for or had any symptom or indication of abnormal blood sugar, diabetes, gestational diabetes, goiter, hyperthyroidism, hypothyroidism, lymph or gland disease or disorder or any other thyroid or endocrine disease or disorder?

Rows	Yes	No
Proposed Insured
Owner / Payor

Blood 4. Have you ever been treated for or had any symptom or indication of a bleeding disorder, anemia, hemophilia or any other blood disease or disorder?

Rows	Yes	No
Proposed Insured
Owner / Payor

Gastrointestinal System 5. Have you ever been treated for or had any symptom or indication of cirrhosis, Crohn’s disease, diverticulitis, hepatitis (including hepatitis carrier state), irritable bowel syndrome, jaundice, pancreatitis, persistent diarrhea, hemorrhoids or intestinal bleeding, ulcer (peptic or gastric), ulcerative colitis, or any other disease or disorder of the bowel, stomach, pancreas or liver?

Rows	Yes	No
Proposed Insured
Owner / Payor

Eyes, Ears, Nose, Throat and Mouth 6. Have you ever been treated for or had any symptom or indication of blindness, deafness, glaucoma, impaired hearing, labyrinthitis, optic neuritis, permanent or temporary loss of vision in either eye or any other disease or disorder of the eyes, ears, nose, throat or mouth (excluding routine check-ups where no follow-up is required, such as tonsillectomy, adenoidectomy, sinusitis or any other disorder requiring eye glasses, contact lenses or ear tube)?

Rows	Yes	No
Proposed Insured
Owner / Payor

Respiratory System 7. Have you ever been treated for or had any symptom or indication of asthma, chronic obstructive pulmonary disease (COPD), chronic or recurrent bronchitis, cystic fibrosis, difficulty of breathing, shortness of breath or hoarseness, emphysema, persistent cough, sarcoidosis, sleep apnea, spitting of blood, tuberculosis, or any other respiratory disease or disorder?

Rows	Yes	No
Proposed Insured
Owner / Payor

Mental Health 8. Have you ever been treated for or had any symptom or indication of an eating disorder, attempted suicide, attention deficit disorder (ADD), burnout, chronic anxiety, chronic fatigue syndrome, depression, schizophrenia, or any other psychological, emotional or nervous disease or disorder?

Rows	Yes	No
Proposed Insured
Owner / Payor

Skin and Connective Tissue 9. Have you ever been treated for or had any symptom or indication of a skin lesion, an abnormal mole or nevus, basal cell carcinoma, chronic skin infection, lupus, scleroderma, or any other skin disease or disorder (excluding poison ivy, contact dermatitis, acne, rosacea, sunburn and eczema)?

Rows	Yes	No
Proposed Insured
Owner / Payor

Reproductive and Urinary Systems 10. Have you ever been treated for or had any symptom or indication of abnormal mammogram, abnormal pap smear, breast lump or cyst, tumor, disease or disorder of the genital organ, disease or disorder of the ovary or uterus, hysterectomy, abnormal prostate disease or disorder, sexually transmitted disease, sugar, blood or protein in urine, urinary tract infection, or any other kidney or bladder disease or disorder?

Rows	Yes	No
Proposed Insured
Owner / Payor

Muscular and Skeletal Systems 11. Have you ever been treated for or had any symptom or indication of arthritis (rheumatoid, psoriatic or osteoarthritis, fibromyalgia, muscular dystrophy, numbness or weakness of an arm or leg, paralysis, or any other disease or disorder of the muscles, joints, limbs, back or bones?

Rows	Yes	No
Proposed Insured
Owner / Payor

Nervous System and Others 12. Have you ever been treated for or had any symptom or indication of fainting epilepsy or seizure, dizziness, loss of consciousness, loss of sensation or speech, severe headache, tremor, developmental delay, autism, Down syndrome, cerebral palsy, multiple sclerosis (MS), Alzheimer’s disease, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, coma, dementia or cognitive impairment, or any other disease or disorder of the brain or nervous system?

Rows	Yes	No
Proposed Insured
Owner / Payor

D. Medical Test and Consultations.

1. Have you ever been tested for or has anyone ever recommended that you be tested for exposure to HIV or AIDS?

Rows	Yes	No
Proposed Insured
Owner / Payor

2. Have you ever been treated for or had any indication of AIDS, HIV infection or any other disease or disorder of the immune system?

Rows	Yes	No
Proposed Insured
Owner / Payor

3. In the last 5 years, have you had any medical or diagnostic tests, such as X-rays, ECG scans, MRI, ultrasounds, biopsies or blood tests?

Rows	Yes	No
Proposed Insured
Owner / Payor

4. In the last 5 years, have you been admitted to a hospital or other medical facility, or are you currently awaiting test results? (Exclude miscarriage, vasectomy, tubal ligation, appendectomy, hernia repair, child birth, cosmetic surgery or gall bladder surgery)

Rows	Yes	No
Proposed Insured
Owner / Payor

5. In the last 5 years, have you had an illness or surgery which prevented you from performing your usual activities or the regular duties of your occupation for a period exceeding two (2) weeks?

Rows	Yes	No
Proposed Insured
Owner / Payor

6. Do you have any symptom for which you have not yet consulted a physician or received treatment? (Exclude common cold, flu or seasonal allergy symptom)

Rows	Yes	No
Proposed Insured
Owner / Payor

7. Are you pregnant? Do you have any history of pregnancy complication?

Rows	Yes	No
Proposed Insured
Owner / Payor

Number of months if pregnant

8. Are you taking any medication?

Rows	Yes	No
Proposed Insured
Owner / Payor

If you answered “yes” to any of the questions above, provide details below.

List each condition along with all related treatments, dates, durations, results, names and addresses of doctors, hospitals and clinics consulted. Note: If more space is required, use Supplemental Application Form.

Proposed Insured (Please browse to the right to fill out all the details) ------->

Rows	Question Number	Date	Reason for Check-up	Result and Diagnosis	Treatment and Medication Received	Name and Address of Doctor, Clinic or Hospital
1
2

Owner / Payor (Please browse to the right to fill out all the details) ------->

Rows	Question Number	Date	Reason for Check-up	Result and Diagnosis	Treatment and Medication Received	Name and Address of Doctor, Clinic or Hospital
1
2

DISCLOSURE ON MEDICAL INFORMATION DATABASE .

In accordance with the Insurance Commission’s Circular Letter No. 2016-54, your medical information will be uploaded to a Medical Information Database accessible to life insurance companies for the purpose of enhancing risk assessment and preventing fraud. Once uploaded, all insurance companies will only have limited access to your information in order to protect your right to privacy in accordance with law. A copy of Circular Letter No. 2016-54 may be accessed at the Insurance Commission’s website at www.insurance.gov.ph.

DECLARATION ON THE PROPOSED REPLACEMENT OF EXISTING POLICY (IES).

PART I - (For the Applicant to answer)

1. Total Life Insurance In force on Proposed Insured:

Rows	Company	Basic/Cover	Accident Rider/Year of Issue
.
.
.

2. Has there been or will there be any change in any existing Insurance in force?

3. Will premiums for the insurance applied for be paid by a policy loan from any existing policy?

If yes, please furnish details (name of company, policy number and amount of insurance being replaced

Reminder

It is usually disadvantageous to REPLACE existing life insurance policy(ies) with a new one. Some disadvantages are:

* You may not be insurable on standard terms.
* You may have to pay a higher premium in view of higher age.
* You may loose financial benefits accumulated over the years.

Please take note that in your own interest, we would advise that you consult your present insurer before making final decision. Hear from both sides and make a careful comparison. You can then be sure that you are making a decision that is in your best interest.

REPLACEMENT NOTIFICATION FORM).

Proposed Insured Name

Please put N/A if Not Applicable

Date of Birth

Please put N/A if Not Applicable

Address

Please put N/A if Not Applicable

Name of Applicant if Other Than Insured

Please put N/A if Not Applicable

Company Name (as it appears on the policy)

Please put N/A if Not Applicable

Insured’s Name (as it appears on the policy)

Please put N/A if Not Applicable

Policy No.:

Please put N/A if Not Applicable

Note: The replacing insurer should furnish a copy of this form to the issuer of the policy being replaced within seven (7) days from the receipt of the application.

DECLARATION AND AGREEMENT

I/WE UNDERSTAND, DECLARE AND AGREE THAT:

1. There shall be no contract of insurance unless and until this Application has been approved, the Policy is issued on this Application, and the full first premium of the basic life insurance and any special benefit applied for, according to the mode of payment specified in answer to Part II, is actually paid during the lifetime and good health of the Proposed Insured.

2. The answers or statements made in this application and in any other document attached thereto and/or forming part of this application (hereinafter called this “Application”), are true, complete, correctly recorded and have been given with full consent and shall form part of and be the basis of the insurance contract herein applied for. If a material fact is not disclosed in this Application, the Policy may not be valid. I understand that if in doubt as to whether a fact is material, it will be disclosed to BenLife. Concealment or failure to make a full disclosure, misrepresentation and false declaration covering this Application will cause the insurance to be void. In case of apparent errors or omissions in this Application, or if BenLife is unwilling to issue a policy applied for, BenLife can correct this Application through the “Home Office Endorsement” section and issue a policy based on such amended Application.

3. An electronic copy of this Application shall be binding to me/us and shall be considered as good as the original manually signed document. I/We will inform BenLife of any discrepancy between the electronic copy and the original as soon as possible, and I/we understand that absent any correction within a reasonable period, BenLife is entitled to rely on the electronic copy exclusively.

4. I understand that if I designate an irrevocable beneficiary, I cannot make any changes under the policy that will adversely affect the ownership interests of the irrevocable beneficiary. These changes include, but are not limited to, making a partial/full withdrawal from the policy, taking out loans against the cash value of the policy, assigning or surrendering the policy, or even changing an irrevocable beneficiary, without the written consent of the irrevocable beneficiary/ies.

5. Participating Life Insurance (if Applicable)
I/We understand that in a participating life insurance policy, the owner is eligible to receive dividends subject to the following limitations / conditions:

(I) Beneficial Life in its sole discretion determines the amount of dividends, if any; (ii) dividend rates will typically vary based on the performance of a number of factors, including mortality experience, taxes, inflation, policy owner termination experience, and policy expenses, with the investment return of Beneficial Life being the main determinant of dividend; and (iii) considering the variability of dividend performance , it is not guaranteed that there will be a dividend accumulation sufficient to offset any future premiums or the policy will become self-liquidating or able to pay its own premiums in the future

6. During the effectivity of the contract/policy, the I/We agree to the following:

(I) ln case BenLife is unable to comply with relevant customer due diligence (CDD) measures, as required under the Anti-Money Laundering Act, as amended and relevant issuances due to my/our fault, BenLife may apply the following: a. Measures to restrict the services available or prohibit any further transactions on the contract/policy until full and proper CDD measures have been successfully conducted; and b. ln case the foregoing is unsuccessful, terminate business relationship. The exercise of BenLife of this measure shall only entitle me/us to receive the unused portions of premium or withdrawal value, if any, whichever is applicable. (ii) Be bound by obligations set out in relevant United Nations Security Council Resolutions relating to the prevention and suppression of proliferation financing of weapons of mass destruction, including the freezing and unfreezing actions as well as prohibitions from conducting transactions with designated persons and entities.

7. My/our policy contract, respective billing notices and future correspondences, if any, will be sent electronically to the email address in my record. I understand that I can request for printed copies through the Customer Care Hotline, or at any BenLife Office.

8. BenLife collects and uses my/our personal and sensitive information to operate an insurance business. By signing this Application and continuing to avail of BenLife’s products and services, I/We agree that the information I/We provided and any subsequent changes to it (including the information of third parties) can be processed, shared, disclosed, transferred or used by BenLife, including its shareholders, directors and employees, affiliates, subsidiaries, business partners, advisors, representatives, industry associations and databases, regulatory authorities having jurisdiction over BenLife, external auditors/counsels, and its third party service providers (whether within or outside the Philippines) within the rules set by the Data Privacy Act of 2012, as may be amended from time to time, relevant regulations and the BenLife’s privacy policy for purposes of: (i) underwriting and approving my Application; (ii) administering, serving, and reinsuring my policy; (iii) marketing, promoting, getting feedback on BenLife’s products and services, and measuring client satisfaction; (iv) conducting data analytics and doing automated data processing; (v) preventing money laundering or terrorist financing activities; (vi) complying with regulatory and reportorial requirements as well as other legal, regulatory or contractual obligations relating to information sharing; (vii) BenLife’s internal purposes such as governance, risk, actuarial, claims and underwriting management, and reporting; and (viii) for other reasonable purposes related to the services provided.

9. For the information I/We gave: (i) BenLife shall keep them in line with its record retention policy; (ii) I shall inform BenLife of any changes in them as soon as possible; (iii) I will not hold the company responsible for any claims, loss, liability and cost as a result of using them for valid purposes.

10. I am/We are allowing any licensed physician, medical practitioner, hospital, clinic or any other medically-related facility, insurance company, medical information database or any other public or private company, entity, government agency, individual, financial institutions or persons who has/have any of my/our records to give to BenLife and its reinsurer my/our information to verify my/our identity, to independently verify, the correctness of the collected data, authenticity of the identification, supporting documents, and any other information I/we submit to BenLife as may be required by this Application. A photocopy of this authorization shall be considered valid as the original.

11. Before signing this Application, I/we have carefully read the same and the questions were fully explained to me/us in a language/dialect which I/we understand.

Signature of Life Insured

Printed Name of Life Insured

First NameMiddle NameLast Name

Signature of Policy Owner

Printed Name of of Policy Owner

First NameMiddle NameLast Name

Signature of Parent / Guardian if assured is minor.

Printed Name of Parent / Guardian if assured is minor.

First NameLast Name

Place of Signing

YOUR TEMPORARY POLICY NUMBER

PAYMENT DETAILS

Upload Client Payment

Please limit your file upload to 2mb

Amount Paid

Financial Advisors' Name

Financial Advisors Email

Selected Name from Dropdown will be sent to this Email

Underwriters' Code

Select your Underwriters' Code

PART II - (For the Agent to answer)

1. Has there been or will there be any change in any existing insurance in force on the life of proposed insured?

2. Will premiums for the insurance applied for be paid by policy from any existing policy?

If yes, have the applicant complete a Replacement Notification Form

AGENT'S REPORT AND DECLARATION (FOR AGENT' USE ONLY) .

Rows	Yes	No	If No, provide details
Did you personally see the proposed insured and/or applicant for this application?

How long have you known the Proposed Insured and/or Owner/Payor?

Rows	Yes	No	If Yes, provide details
Are the proposed insured and/or owner related to you?
Are you aware of any factor (health or otherwise) which you feel is not disclosed in the application but could affect the underwriting of this application?

Information on the spouse of the Proposed Insured/Owner

Rows	Name	Age	Occupation	Monthly Income
.

Rows	Yes	No	If No, provide details
Are you aware of any factor (health or otherwise) which you feel is not disclosed in the application but could affect the underwriting of this application?

Rows	Inforce Life Insurance	Inforce Life Insurance	Amount of Coverage
.

Other additional remarks:

Identification Documents presented:

Rows	.
TIN
National ID No.
SSS/GSIS/UMID No.
PRC No.
Passport No.
Driver’s License No.

(For Minor)

Rows	.
School ID
Birth Certificate.

(For Foreign Nationals)

Rows	.
ACR ID No.
Passport No.SIRV: (Special Investor’s Resident Visa or SRRV: Special Retirement Resident Visa)
Others

By signing on this form, I declare that I have personally arranged and/or advised on this insurance application form; checked the identity of the Proposed Insured and/or Owner against the identification documents given above; reviewed the original copies of these identification documents, and any photocopy of these that are attached to this application is a true and faithful copy of the original; and interviewed the Proposed Insured and/or Owner before this application is submitted AND, I certify to the best of my personal knowledge and based on official records, that the information provided above is true, correct and complete. I agree that I will submit a new report within five (5) business days if any certification on this report becomes incorrect.

Agent's Signature

Printed Name of Agent

Date

Metro South Email

In the last 12 months, has there been any weight loss of more than 10lbs (4.5kgs)?

In the last 12 months, has there been any weight loss of more than 10lbs (4.5kgs)?