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PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION APPLICATION FOR LIFE INSURANCE
14th Floor Sage House, 110 V.A. Rufino Street,
Legaspi Village, Makati City 1229 Philippines
Telephone +632 8772 9200 Fax +632 8772 9293
www.paramount.com.ph APPLICATION / POLICY NO.
Very Important Reminders: Please answer each question fully and truthfully. Only applications with complete answers to all questions will be processed. Any erasures
on this page and on the reverse should be countersigned by the Proposed Insured & Applicant Owner; otherwise, it may invalidate this application.
PERSONAL INFORMATION ON THE PROPOSED INSURED (PI) PERSONAL INFORMATION ON THE OWNER (If other than the PI)
1. FIRST NAME MIDDLE NAME LAST NAME 24. FIRST NAME MIDDLE NAME LAST NAME

Jodi Rix Novio Gerilla Jyne Rose Serio Gerilla

2. OTHER NAME (Maiden name required if married female, Alias,etc.) 25. OTHER NAME (Maiden name required if married female, Alias,etc.)
N/A Jyne Rose Cabillo Serio
3. DATE OF BIRTH (mm-dd-yyyy) 4. AGE 5. PLACE OF BIRTH 26. DATE OF BIRTH (mm-dd-yyyy) 27. AGE 28. PLACE OF BIRTH

May-23-1989 34 Pastrana, Leyte June-22-1992 31 Tacloban, City

6. GENDER 7. CIVIL STATUS 8. NATIONALITY 29. GENDER 30. CIVIL STATUS 31. NATIONALITY
/
Male Single /
Married Filipino Male Single Married
Filipino
Female Widowed Separated Female Widowed Separated
9. Please // RESIDENCE ADDRESS 32. Please  RESIDENCE ADDRESS
check Brgy. Calsadahay Pastrana, Leyte check
your your
Brgy.Manaybanay Pastrana, Leyte
preferred  BUSINESS ADDRESS / SCHOOL ADDRESS (IF STUDENT) preferred  BUSINESS ADDRESS / SCHOOL ADDRESS (IF STUDENT)
billing billing
address Brgy. Baras Palo,Leyte address N/A
10. NAME OF COMPANY / BUSINESS / EMPLOYER / SCHOOL (IF STUDENT) 33. NAME OF COMPANY / BUSINESS / EMPLOYER / SCHOOL (IF STUDENT)
Wall Street Courier Inc. Deped
11. NATURE OF BUSINESS / OCCUPATION 12. PLACE OF WORK 34. NATURE OF BUSINESS / OCCUPATION 35. PLACE OF WORK
Logistics Palo, Leyte Teacher Pastrana District
13. EXACT OCCUPATION / DESIGNATION 14. OCCUPATIONAL DUTIES 36. EXACT OCCUPATION / DESIGNATION 37. OCCUPATIONAL DUTIES
Rider Parcel Delivery Secondary Teacher Teaching staff/Faculty
15. SOURCE OF FUND 38. SOURCE OF FUND
Salary Salary
16. RESIDENCE TELEPHONE 17. OFFICE TELEPHONE 39. RESIDENCE TELEPHONE 40. OFFICE TELEPHONE

N/A 321-9168 321-2525 321-1234

18. MOBILE NO. 19. EMAIL ADDRESS 41. MOBILE NO. 42. EMAIL ADDRESS
09451359244 Aaronjacob784@gmail.com 09056726249 Gerillajynerose@gmail.com
20. FAX NO. 21. TIN 22. SSS / GSIS# 43. FAX NO. 44. TIN 45. SSS / GSIS#
N/A 02-786321 02-1234567 FS-1256 02-123788 02-123458
23. RELATIONSHIP (OF PI) TO OWNER 46. SUBSEQUENT OWNER
Spouse N/A
47. APPLICANT OWNER BANK ACCOUNT DETAILS (Paramount Life may send me the policy benefits &/or refund of my deposit or premium payment, if any
& applicable, via electronic fund transfer / online bank transfer to my bank account specified below.)
BANK NAME: BANK LOCATION / BRANCH: ACCOUNT NAME: ACCOUNT NUMBER: ACCOUNT TYPE:
 SAVINGS  CURRENT

48. PLAN AMOUNT INSURED COVERAGE PAYMENT QUOTED INITIAL

PERIOD DURATION MODAL PREMIUM
BASE Value shield 1,000,000 99 yrs. 10 yrs. 60,000
ADB 1,000,000 65 yrs. 10 yrs. 3,000
R
I yrs. yrs.
D
E yrs. yrs.
R yrs. yrs.
S 49. TOTAL MODAL
PDF / FDF TIR LEN Others: _____________________________________ PREMIUM 63,000
50. DEPOSIT PAID TO: 51. PROVISIONAL RECEIPT (PR) NO. 52. PR DATE 53. AMOUNT
 Agent  Others: PAID UPON
090 August 22, 2023 APPLICATION 63,000
54. MODE OF PAYMENT 55. DIVIDEND OPTION 56. PREMIUM DEFAULT 57. METHOD OF PAYMENT 58. CERTIFICATE OF
 Annual (Dividends are not guaranteed.) OPTION, (If applicable)  Cash CONDITIONAL
 Semi Annual If participating, dividends if  Premium Loan (PL)  Check / Post Dated Check COVE .
 Quarterly any are to be:  Reduced Paid-Up  Salary Deduction (SD)
 Monthly  Paid in cash Insurance (RPU)  Credit Card 000
 Single Pay  Used to reduce premium  Extended Term  Auto Debit Arrangement (ADA)
 Left to accumulate with interest Insurance (ETI)  Premium Deposit Fund 59. If Universal Life,
(If Monthly, submit complete  Used to buy Paid-Up Insurance Death Benefit Option:
post dated checks or SD or (If no option is chosen, dividends will (ETI will be used if no option (If SD, ADA, or Credit Card, please
ADA or credit card form.) is chosen; otherwise, RPU accomplish pertinent form.) A B
be left to accumulate with interest.) if ETI is not applicable.)
60. NAME/S OF BENEFICIARY/IES (Unless otherwise
indicated in the application, all beneficiaries shall be primary, Relationship Designation
revocable and in equal shares. Please indicate Trustee for Age to Proposed Share
Trustee (if applicable) &
Minor Beneficiary/ies and relationship of Trustee to Minor Insured relationship to the Beneficiary
Revocable Irrevocable
Beneficiary/ies.)
%  
%  
%  
%  
%  
61. LIFE POLICIES IN-FORCE AND PENDING ON PROPOSED INSURED AND OWNER
NAME OF INSURANCE COMPANY PLAN AMOUNT ADB YEAR OF ISSUE
Insured
Owner
62. Has there been or will there be any change in any existing insurance in force? Yes No
63. Will premiums for the insurance applied for be paid by a policy loan from any existing policy? Yes No If yes, please furnish details: (name of
company, policy number and amount of insurance being replaced)

64. Is the policy applied for intended to replace any existing policy with Paramount Life or any other company? Yes No (If yes, please accomplish a
Replacement Notification Form.)
REMINDER: It is usually disadvantageous to REPLACE existing life insurance policy(ies) with a new one. Some disadvantages are: ¨ You may not be insurable on standard
terms. ¨ You may have to pay a higher premium in view of higher age. ¨ You may lose financial benefits accumulated over the years. Please note that in your own interest,
we would advise that you consult your present insurer before making a final decision. Hear from both sides and make a careful comparison. You can then be sure that
you are making a decision that is in your best interest.
65. Home Office Endorsement and/or Additional or Explanatory Remarks / Details of Answers to Questions & Items
Indicate below if any parents, brothers, sisters or children suffered from: diabetes (Indicate if type 1 or 2), stroke, tuberculosis, cancer, high blood pressure,
heart or kidney disease, sickle cell disease, mental illness, suicide or attempted suicide, paralysis, blindness, organ transplant or any disease or illness.
66. ProPosed living deceased
insUred's family Previous & present illnesses / age at current Previous illnesses / age at age at
history state of health onset age cause of death onset death
father
mother
Brothers & sisters
children
67. aPPlicant living deceased
owner's family Previous & present illnesses / age at current Previous illnesses / age at age at
history state of health onset age cause of death onset death
father
mother
Brothers & sisters
children
69. any change in weight within
68. Present height and weight twelve months 70. reason for change in weight

insured ft./ in lbs. lbs. gained lbs. lost

owner ft./ in lbs. lbs. gained lbs. lost

Proposed applicant details of any “yes” answers. Please include reason
declarations regarding ProPosed insUred insured owner for consultation, treatment, diagnosis, date & duration,
(and owner if Payor Benefit is aPPlied for) yes no yes no
name/s & address/es of attending physician/clinic/
hospital/specific tests & results, etc.
Please indicate comPlete details of any “yes” answer.
has the Proposed insured/owner:
71. Ever been active in politics, as a candidate or in any other capacity?
72. Ever driven a motorcycle or engaged in aircraft flying, sky diving, scuba
diving, racing,mountain-climbing or any other hazardous avocation/
activities? If yes,indicate details & accomplish pertinent questionnaire.
73. Have any plan to change occupation or work abroad or stayed in the
last 2 years, or intends to stay for more than 1 month, in a country
different from now? If yes, indicate details, country, purpose, date &
duration, etc.
74. Any pending application for life, accident or health insurance with us or
any other company? If yes, indicate details including company name
and amount of insurance.
75. Ever applied for or received a pension, payment or benefit due to injury,
sickness or disability?
76. Ever had any application for insurance or reinstatement of insurance,
declined, postponed or modified in amount, plan or rate with us or any
other company? If yes, indicate details including company name, etc.
77. Have any family member (spouse, parents, siblings, children, etc.)
who ever had tuberculosis, heart diseases, heart attack, diabetes,
high blood pressure, blood disease, stroke, kidney disease, mental
illness, cancer, blindness, renal failure, paralysis, aids, hiv infection
or any aids or hiv related condition, or any communicable or familial
disease? If yes, please give relation, age at onset, nature of disease,
age at death (if applicable),etc.
78. Ever smoked cigarettes, cigar, or any other form of tobacco? If yes,
indicate date & duration, how many per day, and when was the last time
you smoked.
79. Ever taken any habit-forming substance or drugs, alcoholic drinks,
or had the abuse or treatment for any addiction? If yes, specify and
indicate date & duration, how many per day and when was the last time
you took it.
80. Ever had, or been told to have, or had indication of, or sought
consultation for:
a.Tuberculosis, asthma, emphysema, chronic cough, or any respiratory/
lung disease?
b. Rheumatic fever, high blood pressure, chest pain, defects of the
heart or the blood vessels, or any disorder of the heart or circulatory
system?
c. Hepatitis, ulcer, bowel, liver or gall bladder disease, or any
gastro-intestinal disorder?
d. Renal/kidney stone or any disorder of the genito-urinary or
reproductive system?
e. Brain / mental / eye / ear / nose / throat disorder, epilepsy or any
nervous system disorder?
f. Diabetes, thyroid trouble, cancer, cyst, tumor, lumps/any abnormal
bodily growth or any endocrine/lymph glands or bone/joints/muscles/
skin disorder or injury?
g. aids or hiv infection or related condition, sexually-transmitted
disease, allergies, anemia or any blood or immunological disorder?
h. Continuous or unexplained symptoms of fatigue, weight loss,
diarrhea, enlarged lymph nodes, or unusual skin lesions?
81. Ever been refused as a blood donor or received any blood transfusions
or blood products?
82. Ever had any physical defects, lameness, amputation, abnormality or
deformities?
83. Ever been under observation or had any treatment, accident, injury,
consultation, medical advice, hospitalization, diagnostic test, operation/
surgery, illness, diseases or signs & symptoms of any disease, or
disorder not mentioned above?
84. (for females only)
a. Ever had any complications of childbirth or pregnancy, or abnormal
menstruation?
b. Is the proposed insured/owner now pregnant? If yes, indicate how
many months, date of last menstruation, and number of previous
pregnancies.
i/we hereby declare and agree:
1. that all the foregoing statements, declarations and names in this application together with those stated in any requested medical examinations, questionnaire, or amendment, are complete and
true and correctly recorded and shall form the basis for Paramount Life & General Insurance Corporation to issue an insurance policy and which attachments shall, with the Policy, constitute
the entire contract.
2. that I am authorized to disclose all personal information (sensitive or otherwise) of third parties stated in this application.
3. that there shall be no contract of insurance under this application unless and until during the lifetime and good health of the Proposed Insured and Owner, if also applying for insurance, the Policy
is issued, delivered, and accepted by the Proposed Insured or Owner, and the first full modal premium for the Basic Life and Supplementary Contract/s is actually paid. If, however, a deposit
has been paid at the time of the signing of this application and a certificate of conditional cover has been issued, the terms, conditions and limitations under said certificate of conditional cover
shall apply.
4. that Article 1250 of the Civil Code of the Philippines (RA 386) shall not apply to any payments made or to be made by either party to any contract of insurance, or Policy which shall be issued
pursuant to this application and that the acceptance of any policy issued herein shall be a ratification of any modification made in the space for Home Office Endorsements.
5. that the person who filled this application, his/her being a soliciting agent or any other person, acted under my direction and with my full authority and that before signing, I have read and
understood the same carefully.

signed at this day of 20

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
Place thumbmark if unable Place thumbmark if unable Place thumbmark if unable
of Agent/s or LPP/s to sign of Proposed Insured to sign of Applicant Owner to sign
Special Instructions / Additional or Explanatory Remarks / Details of Answers to Questions & Items on this Application / Additional
Home Office Endorsement.

This is to confirm that my Paramount Life agent has shown me the Proposal for the Plan I accepted to apply for, which includes, if applicable, cash values, projected dividends, scheduled
premium payments & benefits. I further attest everything about the product has been explained to me clearly, and I understand & agree that:
- Cash Values stated on the policy (if applicable) are guaranteed based on schedule.
- Dividends, interest rates, interest on premiums paid in advance (if applicable) are not guaranteed.
- Because I found the proposed insurance plan beneficial to me &/or to my interests, I have signed the application form willingly.
- In the event that I resign/retire from my current work where my insurance is under the Salary Deduction arrangement, I shall request Paramount Life to have my premium payment shifted
from Salary Deduction to an available regular method of payment.
- Paramount Life may send me the policy contract/ premium notices/ statements (if issued), letters & other correspondences, if any & applicable, regarding my insurance application/policy in
electronic form through the email address indicated in this Application or Amendment to this Application, if any, via email, or SMS or MMS or any other form of social media, in lieu of hard
copy, and its security & confidentiality shall be my sole responsibility as Applicant/Policy Owner; In the event of security breach, Paramount Life, its owners, board members, investors,
officers, employees & agents shall be held free and harmless from any and all loss, damage & liability; Electronic premium notices, statements, letters, & other correspondences for my other
previously existing insurance policies with Paramount Life may also be emailed to me thru this same email address as my latest email address, in lieu of hard copy. In case of my failure to
receive & access the electronic premium notices &/or statements, I will not be excused from timely payment of my premium dues. I will immediately inform Paramount Life of any change in
my email address or non-receipt of electronic premium notices &/or statements on time. Paramount Life reserves the right to revert to paper contract, premium notices, statements, letters
& other correspondences if the Epolicy/Electronic Policy System is not available or for any other reason at anytime without disclosing the reason for such action.
- Paramount Life may send me the policy benefits &/or refund of my deposit or premium payment, if any & applicable, via electronic fund transfer / online bank transfer to my bank account
specified on this Application or Amendment to this Application, if any.

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
Place thumbmark if unable Place thumbmark if unable Place thumbmark if unable
of Agent/s or LPP/s to sign of Proposed Insured to sign of Applicant Owner to sign

MEDICAL INFORMATION DISCLOSURE

ln accordance with the lnsurance Commission’s Circular Letter No. 2016-54 your medical information will be uploaded to a Medical lnformation Database
accessible to life insurance companies for the purpose of enhancing risk assessment and preventing fraud.

Once uploaded, all life insurance companies will only have limited access to your information in order to protect your right to privacy in accordance with law.
A copy of Circular Letter 2016-54 may be accessed at the lnsurance Commission’s website at www.insurance.gov.ph

DATA PRIVACY ACT CONSENT STATEMENTS WITH AUTHORIZATION FOR ACCESS TO INFORMATION
I hereby consent to the processing of the personal data stated above whether manually or via electronic channels, including but not limited to the collection,
usage, storage, customer/client profiling, and disclosure to third parties, by Paramount Life & General Insurance Corporation (hereafter, “PLGIC”), its subsidiaries,
affiliates, directors, officers, employees, and agents (a) to verify and/or confirm any or all the information provided or representation made, (b) to provide, facilitate,
monitor, improve the quality of, or otherwise service my account and such products, services, and facilities and/or channels availed by me or may be offered
by PLGIC, (c) for marketing purposes, and (d) to comply with legal, regulatory or other obligations of PLGIC under applicable local or foreign laws, rules and
regulations.

I likewise consent to the processing of the personal data stated above whether manually or via electronic channels, including but not limited to the collection,
usage, storage, and customer/client profiling, by authorized third parties for the foregoing purposes.

Such processing may be conducted for the duration of my availment of PLGIC’s products, services, facilities and/or channels. I further consent that the personal
data stated above shall be retained by PLGIC for an additional period of at least five (5) years, or for a longer period if the personal data is related to or required to
be preserved for litigation or to comply with legal or regulatory requirement. I likewise consent to the correction, amendment, deletion and/or disposal by PLGIC,
its subsidiaries, affiliates, directors, officers, employees, agents, and authorized third parties, of my personal data which may be inaccurate or incorrect.

I attest that I have been made aware of and understood my rights as data subject and how these can be exercised, and that I was informed of the nature, extent and
processing of the personal data I provided. I understand and agree that the consent hereby given may be revoked or withdrawn through formal written notice to PLGIC.

I authorize PLGIC, its subsidiaries, affiliates, directors, officers, employees, agents, and authorized third parties to obtain such other information they may deem
necessary to verify or confirm the personal data declared or the documents furnished in relation to this application, and that I agree that such documents may
remain in the possession of PLGIC whether or not this application is granted, for the purposes above mentioned.

Finally, I hereby authorize and request you, any person, organization or entity that has any record or knowledge of my health and/or that of,
_______________________________ to give to PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION any and all information that they may desire
and which is relative to any consultation, treatment or any other medical advice or examination I/we had. A photocopy (or similar copy) of this authorization shall
be as valid as the original. The request for information is in connection with my application for life insurance.

Signed at this day of 20

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
Place thumbmark if unable Place thumbmark if unable Place thumbmark if unable
of Agent/s or LPP/s to sign of Proposed Insured to sign of Applicant Owner to sign

CCC No.

CERTIFICATE OF CONDITIONAL COVER

(Not to be detached unless settlement of deposit of at least one modal premium has been made at the time of Application.)

This Certificate is issued to the proposed insured and/or Owner as an acknowledgement to the premium deposit made with Paramount Life on the Application for Life
Insurance bearing the same serial number as this Certificate. The proposed insured and/or Owner (when applicable) shall be deemed covered with life insurance
subject to the following conditions:
1. Effectivity of insurance shall be the latest of :
1.1. date of Application (Part I); or,
1.2. date of latest full medical examination, if any.
2. Coverage shall be the amount of basic life insurance and any special benefit/s applied for in said Application. However, inclusive of other existing coverages of
the Proposed Insured (and/or Owner, when applicable) on inforce policies issued by the Paramount Life, such amount shall not be more than;
2.1. P 2,000,000 of life insurance for peso policies or its dollar equivalent for dollar policies; and,
2.2. P 2,000,000 accident benefit/s for peso policies or its dollar equivalent.
Insurance amounts denominated in a currency other than the Philippine Peso shall be converted using the applicable exchange rate prevailing at the time of the
proposed Insured’s death.
When any of these limits is exceeded, Paramount Life shall only be liable up to the limit applicable under this Certificate. That part of the payment corresponding
to the excess coverage applied for shall be refunded. The full amount applied for can only be effective upon approval of the Application by Paramount Life and
payment of the additional premium required, if any, while Proposed Insured/Owner is/are in good health, subject to these limits.
3. The coverage provided by this Certificate shall, in all other respects, be governed by the provisions of the policy applied for.
4. The premium deposit herein acknowledged must be paid to Paramount Life’s Agent / LPP when the Application is completed, dated and signed.
5. On payment of the required premium deposit, this Certificate must be dated and signed by the Agent / LPP at the back portion hereof.
6. The premium deposit shall be in cash or check. If paid by check or other forms of remittance, it will only be valid when honored upon first presentation for
payment.
(Please accomplish continuation at the back.)
7. The premium deposit must not be less than a full modal premium for the basic life insurance and any special benefit/s applied for in accordance with Paramount
Life’s Home Office computation. If the premium deposit is more than such a modal premium, the excess shall be applied to the next premium due; otherwise it
shall be kept on credit subject to the Owner’s direction.
8. If required by Paramount Life, medical requirement or requirements must be completed within 90 days from the application date.
9. This Certificate shall in no case be altered or erased, assigned or transferred.
10. On the effective date of the insurance under this Certificate, the Proposed Insured (and/or Owner, if Payor’s benefit is applicable), must be in good health and
a Medically Standard Risk under Paramount Life’s underwriting rules for the plan and amount of basic life insurance and for the type and amount of any special
benefit/s applied for.
11. If any of the above conditions is not met, no insurance shall, at any time, be effective. The premium deposit shall be refunded to the Owner of the Certificate or
applicable to any modified policy which Paramount Life may issue under the Application and acceptable to the Owner.
12. When effective, the insurance under this Certificate can only be in force not later than ninety (90) days from the date of this Certificate.

I confirm acceptance of this Certificate and certify that I have read and understood its entire contents, as well as the agreement in the Application, all of which have
been fully explained to my satisfaction by the Sales Underwriter and I understand and/fully agree with them.

Signature Over Printed Name Signature Over Printed Name

of Agent/s or LPP/s
Place thumbmark if unable
of Proposed Insured
Place thumbmark if unable Date
to sign to sign

THIS CERTIFICATE OF CONDITIONAL COVER SHALL BELONG TO THE OWNER/INSURED

ONLY UPON ITS COMPLETION, SIGNING, AND PAYMENT OF THE INITIAL PREMIUM DEPOSIT.

IMPORTANT NOTICE: The Insurance Commission, with offices in Manila, Cebu and Davao, is the government office in charge of the enforcement of all laws related to
insurance and has supervision over insurance providers and intermediaries. It is ready at all times to assist the general public in matters pertaining to insurance. For any
inquiries or complaints, please contact the Public Assistance and Mediation Division (PAMD) of the Insurance Commission at 1071 United Nations Ave., Ermita, Manila with
telephone numbers +632-85238461 to 70 and email address pubassist@insurance.gov.ph. The official website of the Insurance Commission is www.insurance.gov.ph
E-340000000-001