CLIENT INFORMATION SHEET

PRINT clearly. Use BLACK ink. Please DO NOT leave any space blank. Indicate N/A if question is NOT APPLICABLE.

A. Life to be Insured
1. Last Name: First Name: Middle Name: 2. Gender: 3. Birthdate (dd/mmm in letters/yyyy):
 Male
 Female
4. Age: 5. Civil Status: 6. Country/ies 7. Birthplace: 8. Citizenship: 9. Philippine TIN: 10. SSS/GSIS/UMID No:
 Single  Married of Legal
 Widowed  Legally Residence:
11. Home Phone: 12. Work Phone: 13. Mobile Phone: *Email:

14. Permanent Residence Address: (No. Street, Village, Subdivision, Brgy., City, Municipality, Province, County, Zip Code)

15. Present Residence Address: (No. Street, Village, Subdivision, Brgy., City, Municipality, Province, County, Zip Code)

16. Primary Occupation/Position or Rank: 17. Details of Duties: 18. Total Years of Employment/Business: 19. Annual Income:

20. Employer or Name of Business: 21. Nature of Business: 22. Business Address:

23. Other Occupation: 24. Previous Occupation and Name of Previous Employer: (if unemployed/retired)

25. Have you ever held or are you currently holding  Smoker Height: Weight: Valid ID Presented:
an elected or appointed government position?  Non-Smoker X  ID No.:
 Yes Position: Expiry Date: (dd/mmm in letters/yyyy)
 No Date/s in the Position:

If Life to Be Insured is a Minor (Below 18 years old)

Student: School Name: ID Requirement:
Grade School Level: Age: (Tick off once received)
 Yes High School Level : 0-1  Baby Book
 No College/University Level: 2-17  N/A
18 and above  Valid Gov’t ID
Complete School Address:

B.Policy Ownership
*** IMPORTANT REMINDERS ***
Who will own the policy?  Tick off once a valid Gov’t ID is  Photocopy
received.  CP Screenshot
 Individual applicant/Initial owner is the SAME as the life to be insured (Proceed to  Check the correct age of the owner/life insured vs. valid ID presented
Section B.2)  Signature in the ID Presented MUST match with the signatures affixed on
 Individual applicant/Initial owner is DIFFERENT from the life to be insured the application form.
(Proceed to Section B.1)  Check the expiration date of the ID presented.
List of Valid Gov’t IDs:

Primary IDs with Expiry Date

 Passport, Driver’s License, Student Permit (Digitized ID), PRC ID (back to back), NBI, Police Clearance (Certificate/Data Card) OWWA, OFW, Seaman’s Book, Firearm License
Card, School ID, Postal ID (Digitized ID), Other IDs issued by the Government *(PNP, AFP)

Primary IDs without Expiry Date

 UMID, GSIS, SSS, Voter’s ID, Senior Citizen, Other IDs issued by the Government *(DOLE, DILG, DPWH)

Note: For expired Driver’s License with OR for renewal, may be accepted with Secondary ID. School ID may be accepted for Students 20 years old and below. School ID
must be signed by the Dean or Principal

Secondary IDs with Expiry Date

 Postal, Barangay (Resident ID Card), Other IDs issued by Government-Owned or Controlled Corporation (GOCCs), Registered by the BSP, SEC and IC

Secondary IDs without Expiry Date

 IBP, TIN, Phil Health, Other IDs issued by Government-Owned or Controlled Corporation (GOCCs), Registered by the BSP, SEC and IC

Note: In case the Client can provide one (1) SECONDARY ID, kindly bring any of these documents: Marriage Certificate (NSO copy), Marriage Contract (NSO copy), Utility
Billing Statement (which contain the name and address of the Client)

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 CLIENT INFORMATION SHEET
Individual Applicant/Initial Owner
26. Last Name: First Name: Middle Name: 27. Gender: 28. Birthdate (dd/mmm in letters/yyyy):
 Male _ _
 Female
29. Age: 32 30. Civil Status: 31. Country/ies of Legal 32. Birthplace: 33. Citizenship: 34. Philippine TIN: 35. SSS/GSIS/UMID No:
 Single  Married Residence:
 Widowed  Legally
36. Home Phone: 37. Work Phone: N/A 38. Mobile Phone: *Email:

40. Permanent Residence Address: (No. Street, Village, Subdivision, Brgy., City, Municipality, Province, County, Zip Code)

41. Present Residence Address: (No. Street, Village, Subdivision, Brgy., City, Municipality, Province, County, Zip Code)

42. Primary Occupation/Position or Rank: 43. Details of Duties: 44. Total Years of Employment/Business: 6 YEARS 45. Annual Income:

46. Employer or Name of Business: 47. Nature of Business: 48. Business Address:

49. Other Occupation: 50. Previous Occupation and Name of Previous Employer: (if
unemployed/retired)

51. Have you ever held or are you currently holding  Smoker Height: Weight: Valid ID Presented:
an elected or appointed government position?  Non-Smoker ID No.:
 Yes Position: Expiry Date: (dd/mmm in letters/yyyy)
 No Date/s in the Position:

B.2. Mailing Address
 Permanent Address How would you like to
 Present Address receive your billing statement
 Business Address and official receipt?
Choose one.
 SMS*+ E-Notice
 SMS*+ Printed Copy
 Printed Copy only
*All your policies will be updated based
on option selected. SMS billing is
available to Phil. Mobile Nos. and
individual accounts
only.

C. Beneficiary
Primary (Beneficiary for proceeds arising from the death of the life to be insured)
Complete Name (Last, Relationship to Citizenship Birthdate: Revocable (R) or
First, Middle Name) the insured (dd/mmm in letters/yyyy) Irrevocable (I)
1. R I
2. R I
3. R I

Contingent (Beneficiary in the event of death of all primary beneficiary/ies

Name (Last, First, Middle) Relationship to the Citizenship Birthdate
insured (dd/mmm in letters/yyyy)
1.
2.

D.Family History:
Of Life to Be Insured Of Applicant or Owner of WPD/WDDD
Family Ages Health Condition/Medical Age at Cause of Death Family Ages Health Condition/Medical Age at Cause of Death
Member (If Diagnosis Death Member (If Diagnosis Death
Alive) Alive)
Father
Mother Mother
Brothers Brothers

Sisters Sisters

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CLIENT INFORMATION SHEET

Documents Checklist for Client’s Signature: Advisor’s Final Closing Checklist:

(Check box if already signed by the Premium Payment received:  Cash  Cheque
Client) Proof of Temporary Life Insurance issued  Yes  No
 Proposal Copy of Valid Gov’t ID received:  Yes  No
 Application Form APP Serial No.
 FNA Form PR No.
 Amendment of Application (AOA) Form

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