Individual Application Form

Policyholder / Employer *

Name of Insured / Employee *

Address *

Nationality *

Civil Status *

Gender *

Tel. No *

Place of Birth *

Birth Date *

Height *

Weight (lbs) *

TIN *

SSS / GSIS *

Occupation *

Place of Work *

Source of Income *

Amount of Insurance *

Beneficiary Information

Name of Beneficiary *

Age *

Relationship to Insured *

I hereby apply for group insurance and I certify that the foregoing statements and answers are full, complete and true. I agree that they shall be the bases of the insurance for me under the Group Policy. I authorize any physician, nurse, hospital, clinic, or any other insurance company or organization to disclose to PhilLife or its authorized employee or representative any and all information regarding my medical history/medical records/investigation reports in connection with this Application. Further, I authorize PhilLife to process and retain the foregoing statements and answers in accordance with R.A. No. 10173, the Data Privacy Act of 2012, R.A. No. 9510, the Credit Information System Act, and IC Circular Letter No. 2016-54. PhilLife shall not be liable for any claim on account of illness, injury or death, the cause of which was known to me prior to approval of my Application for insurance and withheld or concealed in the above statements.

I fully understand and agree to the terms and conditions of this group insurance. *

Signature of Insured *

Date *

INDIVIDUAL APPLICATION FORM

(for Group Plans)

Beneficiary Information

Signature of Insured *

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