Cujardo Jason Nathaniel Arellano

06/12/1994 Kolambugan, Lanao Del Norte ✔

Filipino ✔ ✔

Tres Aliños Street. Poblacion, Talisay City, Cebu Province

06-3914106-8 +63 933 930 5408 +63 933 930 5048 jcuj12@gmail.com

Synchrony Global Services PHL. Inc. Customer Service Representative

✔ ✔

Jason Nathaniel Digitally signed by Jason Nathaniel A. Cujardo

DN: cn=Jason Nathaniel A. Cujardo, o, ou,
email=jcuj12@gmail.com, c=PH
A. Cujardo Date: 2021.12.12 20:55:58 +08'00'

Jason Nathaniel A. Cujardo

12/12/2021

12/12/2021
Synchrony Global Services
Philippines Inc.

Jason Nathaniel A. Cujardo

Customer service representative

Digitally signed by Jason Nathaniel A.

Jason Nathaniel Cujardo
DN: cn=Jason Nathaniel A. Cujardo, o,
A. Cujardo ou, email=jcuj12@gmail.com, c=PH
Date: 2021.12.12 20:56:54 +08'00'
 Individual Application
for Group Life Insurance
THE MANUFACTURERS LIFE INSURANCE CO. (PHILS.), INC. ESP NEL and Below
Head Office: LKG Tower, 6801 Ayala Avenue, Makati City, 1226 Philippines
Tel. Nos. 88-4-LIFE (884-5433) / 884-7000 • Fax: 885-7412

Please answer completely and accurately. If possible use black ink. Any change should be initialled by proposed insured and/or owner/payor.
Policyholder Policy Number

PROPOSED INSURED’S INFORMATION
Name (Title) (Last) (First) (Middle)
Cujardo Jason Nathaniel Arellano

Date of Birth (YYYY/MM/DD) Sex [ ✔ ] Male Civil [ ✔] Single [ ] Married Height [ ] cm Weight [ ✔ ] lbs Place of Birth

1994/06/12 [ ] Female Status [ ] Separated [ ] Widowed
5'9 [ ✔ ] ft/in 219 [ ] kls Ko;ambugan, Lanao Del Norte

Permanent Residence Address (Number, Street, City & Province) Citizenship

279 Tres Aliños Street, Talisay City, Cebu Province Zip Code [ 6045 ] Filipino
Office Address (Number, Street, City & Province)
Self-Declaration Statement
15th to 17th Floor Ayala Center Cebu TowerBohol Street, Cebu Business Park Check the box that applies:
Cebu City, Cebu Zip Code [ 6000 ]
[✔] [ ]
Contact Numbers Residence Office Mobile I acknowledge that I I acknowledge that I am
(specify area code) +63 09339305408 am not a United States a United States Citizen,
Citizen, United States United States Permanent
Email Occupation TIN or SSS/GSIS Permanent Resident Alien Resident Alien (Green
jcuj12@gmail.com Customer Service Representative 06-3914106-8 (Green Card Holder) or a Card Holder) or a United
United States Resident. States Resident.
Date of Employment Effective Date of Insurance Amount of Insurance

Date of Birth Relationship of

Beneficiary/ies Place of Birth Revocable Irrevocable Citizenship
(YYYY/MM/DD) Applicant
Primary [ ] [✔ ]
Karen Joy Arellano Cujardo 1971/12/28 Cebu City Filipino Mother
Contingent [✔] [ ]
Siegfred Bon Arellano Cujardo 1995/07/21 Kolambugan, Lanao Del Norte Filipino Brother
Trustee to Minor Beneficiary/ies [ ] [ ]

Note : All designated beneficiary/ies are deemed revocable unless stated otherwise.

PRIVACY CONSENT STATEMENT

We, Manulife Philippines (the Company), value and protect our clients’ privacy as we understand that the use of your personal information is important to you.
The collection and use of information is fundamental to our business as it allows us to evaluate, issue and administer the policy you have applied for.

By signing below and submitting this application, you agree that:

• You understand that the Company is a member company of the Manulife Financial Group and it may have obligations to meet the requirements of both
local and foreign regulatory authorities (including local and foreign tax authorities such as the U.S Internal Revenue Service) as well as other legal
obligations from time to time relating to information sharing and tax reporting from time to time (“regulatory and legal requirements”).
• You consent to the use of information provided to the Company and you will provide us with information that we request from time to time and allow
us to share/report such information with our local and foreign authorities (including local and foreign tax authorities) to meet said regulatory and legal
requirement.
• You will notify us as soon as possible of any change in the information that you have provided to us, including any circumstances such as a change in
your residence, address, telephone number and citizenship.
• You hereby waive any rights you may have that would prevent us from meeting reporting requirement mentioned above.

I hereby agree to be covered under the GROUP INSURANCE POLICY issued by The Manufacturers Life Insurance Co. (Phils.), Inc. If contributions are
required from me under the terms of my coverage, I hereby authorize that they be deducted from my pay.
Digitally signed by Jason Nathaniel A. Cujardo
Jason Nathaniel A. DN: cn=Jason Nathaniel A. Cujardo, o, ou,
279 Tres Aliños St. Talisay City, Cebu Province Cujardo email=jcuj12@gmail.com, c=PH
Date: 2021.12.12 20:57:42 +08'00'
Signed at _____________________________________ By _________________________________________________________
Signature of Applicant

12/12/2021
Date ______________________________________ Witness _______________________________________________________
Signature over Printed Name

Form No. GAT005-A (0414)

 PMRF
PHILHEALTH MEMBER REGISTRATION FORM
UHC v.1 January 2020

1 2 0 2 5 5 8 6 7 1 4 3
REMINDERS:
PHILHEALTH IDENTIFICATION NUMBER (PIN)
1. Your PhilHealth Identification Number (PIN) is your unique and permanent
PURPOSE:
number.
2. Always use your PIN in all transactions with PhilHealth. REGISTRATION UPDATING/AMENDMENT
3. For Updating/Amendment check the appropriate box and provide details to Preferred KonSulTa Provider
be accomplished and submit corresponding supporting documents.
4. Please read instructions at the back before filling-out this form.

I. PERSONAL DETAILS
NAME NO
MIDDLE MONONYM
LAST NAME FIRST NAME EXTENSION MIDDLE NAME NA ME
(Jr./Sr./III)
(Check i f app li cable onl y)

MEMBER Cujardo Jason Nathaniel Arellano

MOTHER’s
MAIDEN NAME Arellano Karen Joy Otadoy

SPOUSE
(If Married)

DATE OF BIRTH PLACE OF BIRTH (City/Municipality/Province/Country)

(Please indicate country if born outside the Philippines) PHILSYS ID NUMBER (Optional)
0 6 1 2 1 9 9 4
Kolambugan, Lanao Del Norte
m m d d y y y y
SEX CIVIL STATUS CITIZENSHIP TAX PAYE R IDE NTIFICATION NUMBER (TIN) (Optional)
✔ Single Annulled
✔
Male ✔ FILIPINO FOREIGN NATIONAL
Female Married Widow/er
Legally Separated
DUAL CITIZEN

II. ADDRESS and CONTACT DETAILS

PERMANENT HOME ADDRESS Hom e Phone Number
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name
279 Tres Aliñons Street
(COUN TRY C OD E + AR EA CODE + TEL EPHONE NUM BER)
Subdivision Baranga y Municipality/City Province/Sta te/Country (If abroad) ZIP Code
Mobile Number (Required)
Poblacion Talisay City Cebu Province Philippnes 6045
0933 930 5408
MAILING ADDRESS SAME AS ABOVE
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Bus iness (Direct Line)

Subdivision Baranga y Municipality/City Province/Sta te/Country (If abroad) ZIP Code E-mail Address (Required for OFW)
jcuj12@gmail.com

III. DECLARATION OF DEPENDENTS (Use additional form if necess ary )

DATE OF NO Chec k if
NA ME MIDDLE MONONYM
BIRT H with
LAST NAME FIRST NAME EXTENSION
(Jr./Sr./III)
MIDDLE NAME RELATIONSHIP
(mm-dd-yyyy)
CITIZENSHIP NA ME Per manent
Disa bility
(Check i f app li cable onl y)

Cujardo Karen Joy Arellano Mother 12-28-1971 Filipino ✔

Cujardo Jerry Gabucan Father 06-11-1968 Filipino

Cujardo Siegfred Bon Arellano Brother 07-21-1995 Filipino

IV. MEMBER TYPE

DIRECT CONTRIBUTOR INDIRECT CONTRIBUTOR
Employed Private Kasambahay Family Driver
Listahanan LGU-sponsored
Employed Government Migrant Worker
4Ps/MCCT NGA-sponsored
Professional Practitioner Land-Based Sea-Based
Senior Citizen Private-sponsored
Self-Earning Individual Lifetime Member
Filipinos with Dual Citizenship / Living Abroad PAMANA Person with Disability
Individual
KIA/KIPO PWD ID No. ______________
Sole Proprietor Foreign National
Group Enrollment Scheme PRA SRRV No. _____________________ Bangsamoro/Normalization
____________________ ACR I-Card No. _____________________
For PhilHealth Use only:
PROFESSION: (Except Employed, Lifetime Members and MONTHLY INCOME: PROOF OF INCOME: Point of Service (POS) Financially Incapable
Sea-based Migrant Worker)
Financially Incapable

This form ma y be reproduce d and is not f or sale Continue at the bac k

 V. UPDATING/AMENDMENT
Please check: FROM TO
Change/Correction of Name
(Last Name, First N ame, Name Extension (Jr./Sr./III) Middle Name)

Correction of Date of Birth

Correction of Sex

Change of Civil Status

Updating of Personal Information/Address/

Telephone Number/Mobile Number/e-mail
Address

FOR PHILHEALTH USE ONLY

Under penalty of law, I hereby attest that the information provided, including the documents I
have attached to this form, are true and accurate to the best of my knowledge. I agree and
authorize PhilHealth for the subsequent validation, verification and for other data sharing
RECEIVED BY:
purposes only under the following circumstances:

 As necessary for the proper execution of processes related to the legitimate and Full Name:
declared purpose;
 The use or disclosure is reasonably necessary, required or authorized by or under the ______________________________
law; and,
 Adequate security measures are employed to protect my information. PRO/LHIO/Branch:

Jason Nathaniel Digitally signed by Jason Nathaniel A. Cujardo

DN: cn=Jason Nathaniel A. Cujardo, o, ou, _____________________________
email=jcuj12@gmail.com, c=PH
A. Cujardo Date: 2021.12.12 20:59:30 +08'00'
Date & Time:
Jason Nathaniel A. Cujardo
_________________________________________________ 12/12/2021
_________________
Member’s Signature over Printed Name Date Plea se affix right
______________________________
thumbmark if unable to write

INSTRUCTIONS

1. All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable, write “N/A.”
2. All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulness and accuracy of all
information provided.
3. A properly accomplished PMRF shall be accompanied by a valid proof of identity for first time registrants, and supporting
documents to establish relationship between member and dependent/s for updating or request for amendment.
4. On the PURPOSE, check the appropriate box if for Registration or for Updating/Amendment of information.
5. Indicate preferred KonSulTa provider near the place of work or residence.
6. For PERSONAL DETAILS, all name entries should follow the format given below. Check the appropriate box if registrant has no
middle name and/or with single name (mononym).

LAST NAME FIRST NAME NAME EXTENSION (Jr./Sr./III) MIDDLE NAME

SANTOS JUAN ANDRES III DELA CRUZ

7. Indicate registrant’s/member’s name as it appears in the birth certificate.

8. The full mother’s maiden name of registrant/member must be indicated as it appears in the birth certificate.
9. Indicate the full name of spouse if registrant/member is married.
10. Indicate the complete permanent and mailing addresses and contact numbers.
11. For updating/amendment, check the appropriate box to be updated/amended and indicate the correct data.
12. For MEMBER TYPE, check the appropriate box which best describes your current membership status.
13. For Direct Contributors, except employed, sea-based migrant workers and lifetime members, indicate the profession, monthly
income and proof of income to be submitted.
14. For Self-earning individuals, Kasambahays and Family Drivers, indicate the actual monthly income in the space provided.
15. In declaring dependents, provide the full name of the living spouse, children below 21 years old, and parents who are 60 years old
and above totally dependent to the member.
16. Dependents with disability shall be registered as principal members in accordance with Republic Act 11228 on mandatory
PhilHealth coverage for all persons with disability (PWD).
17. The registrant must affix his/her signature over printed name (or right thumbmark if unable to write) and indicate the date when the
PMRF was signed.
 HQP-PFF-093
(V04, 01/2019)

REQUEST FOR CONSOLIDATION/

MERGING OF MEMBER’S RECORDS

12/12/2021
________________
Date

Dear Sir/Madam:

I would like to request for the consolidation/merging of my membership records with the
following information:

121291010459
Pag-IBIG MID Number : ________________________________________________
Member’s Name : ________________________________________________
Cujardo Jason Nathaniel Arellano

Last Name First Name Name Extension Middle Name

Present Home Address : ________________________________________________
279 Tres Aliños St. Poblacion, Talisay City, Cebu Province, Philippines
________________________________________________
________________________________________________
Marital Status : ✔ Single/Unmarried  Widow/er  Annulled
 Married  Legally Separated
Contact Number : 0933930508
________________________________________________
Employer/Business Name : ________________________________________________
SYNCHRONY GLOBAL SERVICES PHILIPPINES INC.
Employer/Business Address : 15TH to 17TH Floor Ayala Center Cebu Tower Bohol Street, Cebu Business Park Cebu City, Cebu
________________________________________________
Employer/Business Contact No. : ________________________________________________
032 263 4835
Purpose of Consolidation/Merging :  Short-Term Loan (STL) Application
 Application for Provident Benefits Claim
 Others, please specify _________________________________

Previous Employer/Business Name Previous Employer/Business Address Inclusive Date(s)

1.
2.
3.
4.
5.

Requesting Pag-IBIG Fund Branch: ______________________________

Requested by: Processed by:

Digitally signed by Jason Nathaniel A. Cujardo
Jason Nathaniel A. Cujardo DN: cn=Jason Nathaniel A. Cujardo, o, ou, email=jcuj12@gmail.com, c=PH
Date: 2021.12.12 21:00:19 +08'00'

_______________________________
Jason Nathaniel A. Cujardo __________________________________
Member’s Name and Signature Name and Designation of Authorized Signatory

Approved by:

__________________________________
Name and Designation of Authorized Signatory