Personal Accident Insurance Form

Personal Accident Insurance Form

(COUNTRY BANKERS)
Which plan would you like to inquire about, Workers or Student Group, or Classic Individual or Family Comprehensive Insurance?

INDIVIDUAL/FAMILY PLAN

(COUNTRY BANKERS)
Email*
example@example.com
Name*

First Name and Middle NameLast Name
Please enter your preferred insurance plan*
ex. Comprehensive Family Insurance (Plan A), Classic Individual Plan (P1,177.00), (5th Anniversary Gift Plan B), (5th Anniversary Gift Classic Individual P235)
Address*

Street Address

Barangay/Subdivision

CityState / Province

Postal / Zip Code
Present Occupation*
Age*
Date of Birth*

MonthDayYear
Date
Mobile No.*
Ex. 09260977374
SingleMarriedWidowedOther
MaleFemale
Name of Spouse
(Skip if there's none)
List of Beneficiaries*
Signature*

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WORKERS (GROUP PLAN)

(COUNTRY BANKERS)
Position of the inquirer:
Name of the company:*
ex. ABC Construction Services
Name of the staff inquiring:*
Address of the company:
Email:*
Contact number:
Mobile No.
Based on the table above, which rates are you planning to avail (highlighted in yellow)?
You may choose several options for multiple quotations. Example: Class A – ₱22.00
Class A Workers (Non-hazardous): Accountants, bankers, clerks, office managers, teachers, and other similar non-hazardous jobs.
Class B Workers (Semi-hazardous): Engineers, foremen, carpenters, security guards, drivers, and other similar semi-hazardous jobs.
If the number of employees to be assured exceeds ten (10), please upload an Excel file containing the following details for each employee:
- Assured Name
- Birthdate
- Beneficiary
- Birthdate of the Beneficiary
- Occupation/Position in the Company
Employee List Upload:

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STUDENTS (GROUP PLAN)

(COUNTRY BANKERS)
Name of the staff inquiring:*
Name of the School:*
ex. ABC Construction Services
Position of the inquirer:
Address of the School:*
Email:*
Contact number:
Mobile No.
Number of Students:
Based on the table above, which rates are you planning to avail (highlighted in yellow)?
You may choose several options for multiple quotations. Example: Class A – ₱22.00
Please upload an Excel file containing the following details for each students:
- Assured Name
- Birthdate
- Beneficiary
- Birthdate of the Beneficiary
Student List Upload:

If possible, please upload a list of students to be insured, including their birthdates, beneficiaries, and relationship to their beneficiaries.
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Thank you for completing this
Personal Accident Insurance form.

Once submitted, our team will review your details and contact you with the next steps regarding your coverage and payment instructions.

Please keep an eye on your email or phone for our confirmation.
If possible kindly attach the proof of payment for our reference and processing.

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Personal Accident Insurance Form

INDIVIDUAL/FAMILY PLAN

WORKERS (GROUP PLAN)

STUDENTS (GROUP PLAN)