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Etiqa Enrollment Form

This document contains an individual application for group insurance. It includes personal details of the applicant such as name, date of birth, address, employer, beneficiaries, and health declaration. The applicant declares that all information provided is complete and true. The document also contains details of the insurance plan such as amount, date of effectivity, and premium.

Uploaded by

Prince Jairo Fortuna
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
11 views

Etiqa Enrollment Form

This document contains an individual application for group insurance. It includes personal details of the applicant such as name, date of birth, address, employer, beneficiaries, and health declaration. The applicant declares that all information provided is complete and true. The document also contains details of the insurance plan such as amount, date of effectivity, and premium.

Uploaded by

Prince Jairo Fortuna
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Master Policy Number Effective Date Certificate Number

INDIVIDUAL APPLICATION FOR GROUP INSURANCE


Last Name FORTUNA First Name PRINCE JAIRO Middle Name SAN JOAQUIN

Date of Birth : JUNE 23, 1999 Age : 24 Place of Birth : BMC Nationality : FILIPINO
NAGA CITY

Sex Civil Status TIN/SSS/GSIS Height __5.5__ ms/ft. in.


□ Male □ Single □ Widowed □ Annulled SSS:
□ Female □ Married □ Legally Separated 05-1583277-6 Weight__67__ kgs/lbs

Residence Address: Zone 6, San Antonio Tigaon, Camarines Sur Telephone Number :

Employer/Association/Union : SMART COMMUNICATIONS INC. Mobile Number : 09093121204

Occupation/Position : SOFTWARE Basic Salary : Date Employed/Regularization Source of Income


DEVELOPER 30 000 November 1, 2023 Salary

Plan of Insurance Date of Effectivity Premium

Amount of Insurance Life Riders

Beneficiaries
Name Date of Birth Age Relationship % share in proceeds
Helen San Joaquin Fortuna October 21, 1965 58 Mother
Benjamin Carcer Fortuna April 1, 1961 62 Father

Eligible Dependents
Name Date of Birth Age Relationship

HEALTH DECLARATION
1. I have not now, never had, nor consulted any physician for: cerebral hemorrhage, heart disease, high blood pressure, tuberculosis, kidney disease,
cancer tumor, diabetes, nor any disease, injury nor impairment not mentioned above; nor undergone any operation or hospitalization.

2.3. I have never been declined, accepted substandard, postponed nor offered a policy different from that applied for.I possess sound health, am able
to perform the normal activities in pursuit of my livelihood and am free from any physical or mental infirmity.
EXCEPTIONS: (State in full details)

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

DISCLOSURE:Information Database accessible to life insurance companies for the purpose of enhancing risk assessment and preventing fraud in
accordance with the Insurance Commission’s Circular Letter No. 2016-54, your medical information will be uploaded to a Medical . Once uploaded, all
life insurance companies will only have limited access to your information in order to protect your right to privacy in accordance with law. A copy of
Circular Letter No. 2016-54 may be accessed at the Insurance Commission’s website at www.insurance.gov.ph.

I/We hereby agree that I/we have informed of all my/our citizenships, residencies and tax residencies, and provided with my/our taxpayer identification
number(s). I/We agree to promptly update of any changes to said information. I/We authorize Etiqa Philippines to disclose my/our personal information
to any government or tax authority (within or outside the Philippines) for the purposes of ensuring compliance with applicable laws and regulations.
I/We
agree that Etiqa Philippines shall have the right to: (a) require the claimant(s) and/or payee(s) of the Policy to provide with their above-mentioned
personal information and/or sign such documents as may reasonably require; and (b) disclose said personal information to any government or tax
authority (whether within or out of the Philippines) for the purposes of compliance with applicable laws and regulations. If I/we fail to any of the
abovementioned acts, I/we agree that Etiqa Philippines may provide my/our personal information to such government or taxation authorities to comply
with the
applicable laws and regulations.

Form no. UW-2019

Page 1 of 1
I HEREBY DECLARE that all the foregoing answers and statements are complete and true and correct to the best of my knowledge and belief. I hereby
agree that if there be any fraud and misrepresentation in the above statement material to the risk, the Insurance Company upon discovery with one (1)
year from Effectivity Date of insurance shall have the right to declare such insurance null and void.

_______________________________________ ______October 31, 2023___________ _______________________________________


Witness Date Signed Signature of Employee/Member

For Home Office use only

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