Allianz Life Changer ™️ Application Form

LIFE CHANGER FORM
Allianz
Allianz PNB Life Insurance, Inc.
Position Applying for*
Source:Referral [by whom:*
For online advertisement source, please write FB PAGE or Website name
PERSONAL INFORMATION
Name*

First NameMiddle NameLast NameSuffix
Birth date*

MonthDayYear
Date
Place of birth*
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile No.*
Landline
Email Address*
example@example.com
Marital Status*
If naturalized citizen of the Philippines, give date and place of naturalization and attached photocopy of certificate of naturalization.*
If Married
Name of Spouse
SSSUMID No*
Tax Identification No*
Most recent Life Insurance Company*
EDUCATIONAL BACKGROUND
Type a question*
SCHOOL
COURSE
EMPLOYMENT HISTORY
(List your last 3 employers, beginning with the current or most recent one)

Most recent employer's contact details

(Preferably HR, Immediate Supervisor or Supervisor):
Company Name 1*
Position*
Employment Date (from and to)*
Company Name 2*
Position*
Employment Date (from and to)*
Company Name 3*
Position*
Employment Date (from and to)*
Email Address*
example@example.com
Most recent employer’s contact details
Contact Name*
Position*
Contact Number*
If currently employed, have you already tendered your resignation?*
1. If answer is No, are we allowed to conduct the employment verification?
Type a question*
2 If answer in number 1 is no please provide details*
CONTACT PERSON
Person to notify in case of emergency*
In case of emergency*
Mobile Number*
(Non-relative, not residing in the same address)
YESNO
Have you ever been accused investigatedarrested indicated or convicted of any criminal or civil case If yes please provide details*
Have you ever declared bankruptcy and/or have you ever been declared bankruptcy by regulators/authorities? If yes, please provide details:
If yes please provide details*
YES NO
Have you ever been investigated for any administrative case? If yes, please provide details:
If yes please provide details*
YESNO
Have you ever been terminated or forced to resign from any employment or affiliates of any Insurance Company or Financial Institution? If yes, please provide details:
If yes please provide details*
That | hereby expressly authorize Allianz PNB Life Insurance, Inc.: to use and process, whether manually or via electronic channels, any and all information I have provided above, including Personal and Sensitive Personal Information, to facilitate, monitor, and improve matters pursuant to my application. to share, transfer, and/or disclose the said information to any of its intermediaries, subsidiaries, affiliates, service providers, partners and government agencies for the said purposes. | likewise promise to inform Allianz PNB Life Insurance, Inc. of any change relating to my personal information. I further understand and acknowledge that such Personal Information may be used by AZPNBL to comply with its legal or regulatory obligations under applicable local or foreign laws, rules and regulations relating to matters including but not limited to anti-money laundering and tax monitoring/review/reporting.

I declare that all information supplied above and all other records and documents submitted by me in support of this application are true and correct to the best of my knowledge and belief. I agree that any false record on information supplied may result in rejection of this application or if already accepted, termination of my contract. I agree that a photographic copy of this authorization and waiver shall be valid as the original.
Applicants Printed Name*
Date*

MonthDayYear
Date
Signature*

Clear
UPLOAD YOUR UPDATED RESUME*

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DIPLOMA or TOR*

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2x2 Photo with white background*

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Proof of SSS and TIN

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Should be Empty:

LIFE CHANGER FORM

Allianz

PERSONAL INFORMATION

EDUCATIONAL BACKGROUND

SCHOOL

COURSE

EMPLOYMENT HISTORY

Most recent employer’s contact details

CONTACT PERSON

YESNO

YES NO

YESNO