CHECKLIST OF NEW BUSINESS APPLICATION

MANDATORY FIELDS

PART 2 GENERAL INFORMATION

Surname Gatchalian
Given Name Jenet
Middle Name Ibañes
Maiden Name (for married
women)
Date of Birth 15-Dec-90
Age 28
Nationality Filipino
Place of Birth Pasig City, Metro Manila
Country of Birth Philippines
Gender Female
Civil Status Single
Primary Occupation Secondary School Teacher
Employer Rizal High School
Nature of Work/Business Public Teacher
TIN or SSS or GSIS both 309086289
Gross Annual Income
Net worth
Sources of Funds

ADDRESS DETAILS
Present Address

Zip Code 1606

Country Philippines
Permanent Address

234 Dr. Sixto Antonio Avenue Caniogan asig City

Telephone Number N/A
Mobile Number 0915-095-6710
Email Address jigatchalian15@gmail.com

EMPLOYER BUSINESS ADDRESS

Company Name Rizal High School
Address Dr. Sixto Antonio Avenue Caniogan Pasig City

Zip code 1606

Country Philippines
Telephone Number N/A
Mobile Number 9769472375

BENEFICIARY DETAILS
Beneficiary 1
Surname Gatchalian
Given Name Nolita
Middle Name Ibañez
Gender Female
Birthdate 4-Oct-58
Place of Birth Pasig City
Present Address 234 Dr. Sixto Antonio Avenue Caniogan Pasig City
Relationship to the Insured Mother
% of share
Beneficiary 2
Surname
Given Name
Middle Name
Gender
Birthdate
Place of Birth
Present Address
Relationship to the Insured
% of share
PART 4 Personal and Family Health History
Height 5'2
Weight 120 pounds

Family Details
Parents Father
Age N/A
Health History
Cause of Death
Age at Death

Spouse
Age N/A
Health History
Cause of death
Age at Death

Siblings (indicate if brother

or sister) Sibling 1
Age N/A
Health History
Cause of death
Age at Death

children (indicate if
daughter or son) Child 1
Age N/A
Health History
Cause of death
Age at Death

Health Questionnaire
PART 5
Medical Record Hospital or Clinic Name
Any hospitalization or
confinement N/A
Surgery N/A
Existing illness N/A
Medical maintenance N/A

FOR MINORS
Name of attending physicianN/A
Clinic Address N/A
No of years with physician N/A
Last date of consultation N/A
Reason for Consultation N/A
Results N/A
 for more than 2 beneficiary, print supplemental additional beneficiary (in
colored)

Beneficiary 3

n Pasig City

Beneficiary 4
 Mother

Sibling2 Sibling 3 Sibling 4

Child 2 Child 3 Child 4

Diagnosis/Cause of
Month/Year Hospitalization