GROUP APPLICATION FORM

Corporate Solutions

INSURANCE COVERAGE INFORMATION

GROUP LIFE INSURANCE GROUP MEDICAL INSURANCE CREDIT LIFE INSURANCE
Product Name: Product Name: Product Name:

Group Life Insurance with: Inpatient Hospitalization Credit Life Insurance with:
Accidental Death & (Basic Medical Benefits) with: Accidental Death &
Dismemberment Benefit (AD&D) Major Medical Benefits Dismemberment Benefit (AD&D)
Accidental Death, Outpatient Benefits Total & Permanent Disability
Dismemberment & Disability Maternity Benefit (TPD) Income Benefit
Benefit (ADD&D) Dental Benefit Critical Illness Benefit (CIB)
Total & Permanent Disability Annual Physical Exam Others:
(TPD) Income Benefit Financial Assistance
Terminal Illness Benefit (TIB) Others:
Hospital Income Benefit (HIB)
Critical Illness Benefit (CIB) Medical network/s used:
Others:

Policy Number: Effective Date: Participation type: Non-Contributory

Mode of Payment: Annual Semi-Annual Quarterly Monthly Contributory

CLIENT INFORMATION
Name of
Company/Group

Nature of Business

Business Address

Tel. No. Fax No.

TIN: SSS/GSIS No.

Incorporation/
Registration No. Source of Funds

Other Requirements Pls. attach a certified true copy of your company’s Articles of Incorporation / Partnership, General Information Sheet,
List of Directors/Partners, List of Principal Stockholders owning at least 2% of capital stock

All statements, including those set forth on the attached sheet hereof, are true and complete to the best of my knowledge and belief and they shall
form part of the contract for insurance. I understand and agree that no coverage will be in effect until this application is approved by the Company, the
full amount due is paid, and a Policy is issued and delivered. Certificates will be issued and delivered during the lifetime and good health of the
Proposed Employee/s.

Dated this day of in the year at

Name & Signature of Company Representative Designation of Company Representative

TO BE COMPLETED BY PHILAM LIFE ONLY

Received by (Name of Branch Personnel/CSE) Time & Date Received Premiums Paid (Credit to Acct. 2605.2) OR Number

AGENT/BROKER INFORMATION
Agent’s/Broker’s Name & Signature Agent/Broker Code Mobile Number Email Address

QR-CRS-GCA / Revision 3 / September 2015 PHILAM LIFE CUSTOMER CONFIDENTIAL