ANCHOR INSURANCE BROKERAGE CORPORATION

14th Flr., Taipan Place, F. Ortigas Jr. Rd. Ortigas Center, Pasig City

PROPERTY INSURANCE
APPLICATION FORM
Name of Insured Date of Birth Place of Birth
_________________________________ __________________ ______________________
Mailing Address Nationality Marital Status:
_________________________________ __________________ ______________________
_________________________________ TIN SSS#
_________________________________________ ______________________ ___________________________

Contact Nos.

Landline _____________________ Mobile No _______________________ Email Add _________________________

Name of Employer : Nature of Work (Self-Employment/Business

______________________________________________________________ ___________________________________
Office Address: _________________________________________________________________

DESCRIPTION OF PROPERTY TO BE INSURED

ADDRESS OF PROPERTY TO BE INSURED (if different from Mailing Address)

___________________________________________________________________________________________________

NATURE OF OWNERSHIP AMOUNT OF INSURANCE

Registered Owner (as per Land Title) / Resident
Registered Owner (as per Land Title) / Non-Resident
Tenant
Others, pls specify Registered Owner:
______________________________
Php __________ BUILDING ONLY (land value NOT included)
Php __________ CONTENTS
Php __________ IMPROVEMENTS (for Condominium units ONLY)
Php __________ SPECIAL ASSESSMENT (for Condominium ONLY)

NATURE OF OCCUPANCY ROOF MATERIALS

Residential Galvanized Iron
Commercial Concrete
Mixed Residential & Commercial Color Roof
Others (pls specify)_____________________

TYPE OF HOME CONSTRUCTION OF EXTERIOR WALLS

Single Detached Concrete
Condominium Unit Mixed Concrete & Timber
Townhouse Others, pls specify______________________
Duplex
Apartment

No. of Floors ______ Age of Home : ______ Total Floor Area __________ Mortgage, if any ________

BOUNDARIES (pls. ENCIRCLE the applicable description) LEGEND:

FRONT : BY AFOREMENTIONED STREET A - BY A BLDG OF SAME CONSTRUCTION & OCCUPANCY

RIGHT : A B C D ________________________ B - BY AN OPEN SPACE / VACANT LOT

LEFT : A B C D ________________________ C - BY STREET OR ROAD

REAR : A B C D ________________________ D - OTHERS (pls. specify) ________________________

1
Any previous loss ? (fire, flood, etc.) Any Fire Extinguishing Appliances?
Yes, please specify ______________________ Yes, please specify ___________________
No No

Security Guard? Sprinkler?

Yes Yes
No No

Distance from a creek, river and the likes: one block away more than one block away remote

D E C L A R A T I O N
I Declare to the best of my knowledge and belief , the statements made by me or on my behalf are true and complete, and
I have not withheld any information material to this application. I agree that this application form shall be incorporated
in the contract between me and Anchor Insurance Brokerage Corporation and I agree to be bound by the terms of the
agreement.

Further, I agree and authorize the Company to use and disclose any information (collected or held) with regard to matters
pertaining to this application, to enable the Company, its associated individuals/organizations or independent third parties,
to provide advice or information covering products or services which the Company believes may be of interest to
me or to communicate with me for any purpose.

Identification document submitted, validated against original by :

_______________________________________ ______________
Signature over Printed Name Date

_______________________________ ___________________
Assured’s Signature Date

*Under Republic Act 9160 (nti-Money Laundering Act) as amended by Republic Act 9194 and pertinent regulations, all insurance
companies/brokers are required to satisfactorily establish the identities of all its customers. Hence, Anchor Insurance Brokerage
Corporation reserves the right to not accept and process any application for insurane if the customer fails to provide sufficient
evidence to establish his identity.

PRIVACY STATEMENT:
Anchor Insurance Brokerage Corporation (“AIBC”, “We”, or “Our”) respects your privacy and will keep secure and
confidential all personal information and sensitive personal information (“Personal Data”) We obtain, or which you
may provide in this form, in connection with your insurance policy/ies and relevant services and products availed from
and through AIBC.

In this regard, please read the Privacy Statement of AIBC, a copy of which is hereto attached, pursuant to public Act No.
10173 or the Data Privacy Act of 2012 and the implementing rules, regulations and issuances of the National Privacy
Commission (“Privacy Laws”), and provide your consent on the use of your Personal Data by AIBC, as provided under
the Privacy Laws by signing in the space provided below.

Should you have any questions and/or concerns regarding our Privacy Statement, AIBC’s use of your Personal data, or
your rights in relation thereto under the Privacy Laws, please do not hesitate to contact the AIBC Data Protection
Officer at the following: aibc-dpo@sanmiguel.com.ph and (+632) 689-5505.

__________________________________
Signature over Printed Name of Policy Holder