Individual Enrollment Form for Group Insurance

Personal Information
Last Name First Name Middle Name
FOR PIONEER LIFE USE ONLY
Victa John Cedesan Ramirez
Birthdate (mm/dd/yyyy) Birthplace Age Sex Height Weight Group Policy No.
05/21/1999 Daet, Cam. Norte 22 Male 168 cm 60 kg Certificate No.

Residence Address Civil Status Nationality Effective Date

Purok 1B, Brgy. 3, Mercedes, Camarines Norte Single Filipino
Amount of Insurance:
Contact Number(s) SSS/GSIS Number Tax Identification Number (TIN)
09682937236 34-8626692-8 379511067000 Basic Life

Name of Employer/Association/Creditor Occupation/Position Accident

SPi Technologies, Inc. (Straive) Project Support Staff TPD

Bereavement
Date of Employment/Membership/Loan Term of Loan (if Group Credit Life) Amount of Loan (if Group Credit Life)
Approval (mm/dd/yyyy) Others
07/29/2019 (pls. specify)
Beneficiary Designation
Full Name (Last, First, Middle) of Beneficiary(ies) Birthdate (mm/dd/yyyy) Age Relationship to Insured
Victa, Sunday Bon 01/29/1976 45 y/o Parent
Victa, Mercedes Ramirez 02/01/1980 41 y/o Parent
Victa, Jhade Dianne Ramirez 10/15/2003 17 y/o Sibling

I hereby certify that the personal data contained herein are true and correct.
06/18/2021
John Cedesan R. Victa
Signature over printed name of applicant Date (mm/dd/yyyy)
PIONEER LIFE INC.
Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph