APPLICATION FOR

COMPULSORY INSURANCE COVERAGE FOR AGENCY-HIRED MIGRANT WORKERS

YOUR PERSONAL INFORMATION

Mr. Ms. Mrs.

NAME : AGUILAR JECCA M,
Last Name First Name M.I.
Philippine : PUROK 6 BRGY. CALAPUGAN NATIVIDAD, PANGASINAN 2446
Address

Civil Status : Single Married Separated Widow/er

Birthdate : NOVEMBER 5, 1991 Birthplace : NATIVIDAD, PANGASINAN

TIN : - - - Age : 31
Telephone : Home : - Office : -
Fax : - Mobile : 0906-716-9353
-
Email Address : accej.aguilar@gmail.com
YOUR PASSPORT DETAILS
Name(as it appears : AGUILAR JECCA MARI
on your passport) Last Name First Name Middle Name
Passport No. : P7098153A Issued on: MAY 21, 2019 at: MANILA
YOUR AGENCY
Agency Name : PHIL. ASSIST LIFE MANPOWER CORPORATION
Address : RM 202 CYA LAND BLDG. NO. 282 EDSA EXTN. PASAY CITY
Association :
Contact Nos. : Tel. : -
phil.assistlifecorp2011@yahoo.com
Fax : 887 - 2754
email : Agent :

YOUR WORK

Company Name : NUITEC CORPORATION

Address : NAGANO KEN KAMIINA-GUN MINOWA MACHI NAKAMINOWA 12246
Country : Japan
Nature of Business : SEWING Industry :
Designation : OPERATOR 2
Monthly Compensation: 163, 485 YEN Currency: Japanese Yen year
T.O.C. : From To Contract Yr:

YOUR BENEFICIARY(IES)
s
It is understood that the beneficiaries share equally and are designated primary and revocable unless indicated
otherwise in the "REMARKS" column.

NAME RELATIONSHIP DATE OF BIRTH REMARKS

MELANIE M. AGUILAR SISTER MARCH 8, 1989
JUANITA M. AGUILAR MOTHER AUGUST 27, 1960

I hereby represent and declare that:

a) I am not below 18 years old and have not reached 61 years of age; and
b) I possess sound health and am able to perform normal activities in pursuit of my livelihood free from any
physical and mental infirmity.
I hereby agree that the above questions and answers shall be considered as part of my application for insurance.
I hereby declare that all the foregoing answers and statements are complete, true and correct to the best of my knowledge
and belief.

MARCH 1, 2023
SIGNATURE OF APPLICANT DATE