Personal Accident Insurance Form

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

Students Group PlanWorkers Group PlanClassic Individual/Family Comprehensive Plan

Personal Accident Insurance Form

This insurance gives you financial support in case of accidental injury, permanent disability, or death. Perfect for individuals who want fast, affordable, and reliable protection. With Britanico Insurance Services, you're always one step ahead in safety.
Email*
example@example.com
Name*

First 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
Gender*

MaleFemale
Civil Status*

SingleMarriedWidowedOther
Name of Spouse
(Skip if there's none)
Signature*

Powered by Jotform SignClear

Beneficiary Information

"Please indicate the person who will receive the benefits in the event of a covered incident."
Beneficiary Name*

First NameLast Name
Relationship to You *
Example: Spouse, Child, Parent, Sibling, etc.
Date of Birth of Beneficiary*

MonthDayYear
Date
Address (Optional if the beneficiary does not reside with you)

Street Address

Barangay/Subdivision

CityState / Province

Postal / Zip Code

Beneficiary Information 2

"Please indicate the person who will receive the benefits in the event of a covered incident."
Beneficiary Name*

First NameLast Name
Relationship to You *
Example: Spouse, Child, Parent, Sibling, etc.
Date of Birth of Beneficiary*

MonthDayYear
Date
Address (Optional if the beneficiary does not reside with you)

Street Address

Barangay/Subdivision

CityState / Province

Postal / Zip Code

Beneficiary Information 3

"Please indicate the person who will receive the benefits in the event of a covered incident."
Beneficiary Name*

First NameLast Name
Relationship to You *
Example: Spouse, Child, Parent, Sibling, etc.
Date of Birth of Beneficiary*

MonthDayYear
Date
Address (Optional if the beneficiary does not reside with you)

Street Address

Barangay/Subdivision

CityState / Province

Postal / Zip Code

Beneficiary information 4 (max. 4 children)

"Please indicate the person who will receive the benefits in the event of a covered incident."
Beneficiary Name*

First NameLast Name
Relationship to You *
Example: Spouse, Child, Parent, Sibling, etc.
Date of Birth of Beneficiary*

MonthDayYear
Date
Address (Optional if the beneficiary does not reside with you)

Street Address

Barangay/Subdivision

CityState / Province

Postal / Zip Code

Name of the staff inquiring:*
Position of the inquirer:
Name of the company:*
ex. ABC Construction Services
Address of the company:
Email:*
Contact number:
Mobile No.
Number of Class A workers:
Class A (Non-hazardous): Includes occupations such as accountants, bankers, clerks, office managers, teachers, and other similar non-hazardous jobs.
Number of Class B workers:
Class B (Semi-hazardous): Includes occupations such as engineers, foremen, carpenters, security guards, drivers, and other similar semi-hazardous jobs.
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
Employee List Upload:

If possible, please upload a list of the employees or staff to be insured, including their birthdates, beneficiaries, and relationship to their beneficiaries.
Cancelof

Name of the staff inquiring:*
Position of the inquirer:
Name of the School:*
ex. ABC Construction Services
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
Student List Upload:

If possible, please upload a list of students to be insured, including their birthdates, beneficiaries, and relationship to their beneficiaries.
Cancelof

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.
Should be Empty:

Beneficiary Information