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Beneficiary & Emergency Form
Beneficiary & Emergency Form
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Identity/Resident No.: First Name: Middle Name: Last Name: 77872373 Reynaldo Obille Jornacion Employee No.: Date of Birth: (dd/mm/yyyy) Gender: Marital Status: 66013 09 May 1956 Male Marriage
The Beneficiary designation statement below is for Final Payment payable as a result of the employees death. I authorize payment of my Final Pay to the following beneficiaries. Primary Beneficiary or Beneficiaries: First Name 1 2 3 If more than one primary beneficiary is named, the benefits, unless otherwise stated above, will be paid in equal shares to the designated primary beneficiaries who survive the employee. If no such primary beneficiary survives, the death benefit, unless otherwise state below, will be paid in equal shares to the designated secondary beneficiaries who survive the employee. MARITA Middle Name RAMOS Last Name JORNACION Relationship Wife Percentage (%) Payable 100
Employee Signature:
Reynaldo Jornacion
Landlord Name & Phone No.: N.A. EMERGENCY CONTACT INFORMATION For local Address Name: Marita Jornacion _______________________________ _______________________________ For Home County Address Name: Kennel Rey Jornacion Relationship: Contact No.: Son +63-9327015196 Relationship: Contact No.: Wife 9729-0931
Please Return This Completed From To: Human Resource Department, PICL I confirm that the personal details recorded above true and accurate. Full Name: Date & Signature: Reynaldo Jornacion 23 February 2012