CLIENT INFORMATION SHEET

Owner's Information
Last Name : Advincula
First Name: Trisha Mae
Middle Name: Del Rosario
Gender : Female
Date of Birth : July 29 2004
Age : 19
Status : Single
Birthplace : Manama Bahrain
Nationality : Filipino
TIN : N/A
SSS : N/A
Mobile # : 9177732004

Permanent Address : 11 Pangalinan street, purok 1, new lower Bicutan, MRT

Avenue, NCR fourth District, Tagig
Present Address : R square residences, Taft Avenue, Cor Pablo Ocampo St,
Barangay 709, Malate Metro Manila
Primary Occupation / Position : Student
Nature of Work : Pursuing Bachelor of Science in Cybersecurity
Total Years of Employment : 2 Years as a full time student
Annual Income : Dependent on financial support from parents
Name of Employer : N/A
Nature of Business : N/A
Business Address : N/A

Preferred Mailing Address : [x]Permanent Address []Present Address

Email Address : trisha.mae2429@gmail.com
How would you like to receive billing statement :[x]SMS+Electronic Copy
[]SMS+Printed Copy []Printed Copy Only
Would like to receive personalized communication and product : []Yes [x]No
Relationship to the insured: Self

Insured Information:
Last Name : Advincula
First Name: Trisha Mae
Middle Name: Del Rosario
Gender : Female
Date of Birth : July 29 2004
Age : 19
Status : Single
Birthplace : Manama Bahrain
Nationality : Filipino
TIN : N/A
SSS : N/A
Mobile # : 9177732004

Permanent Address : 11 Pangalinan street, purok 1, new lower Bicutan, MRT

Avenue, NCR fourth District, Tagig city.
Present Address : R square residences, Taft Avenue, Cor Pablo Ocampo St,
Barangay 709, Malate Metro Manila
Primary Occupation / Position : Student

Nature of Work : Pursuing Bachelor of Science in Cybersecurity

Total Years of Employment : 2 Years as a full time student
Annual Income : Dependent on financial support from parents
Name of Employer : N/A
Nature of Business : N/A
Business Address : N/A

Preferred Mailing Address : [x]Permanent Address []Present Address

Email Address : trisha.mae2429@gmail.com
How would you like to receive billing statement :[x]SMS+Electronic Copy
[]SMS+Printed Copy []Printed Copy Only
Would like to receive personalized communication and product : []Yes [x]No

Primary Beneficiary 1
Name : Bernadette Del Rosario Advincula
Relationship : Mother
Citizenship : Filipino
Birthdate :January 9 1972
Contact No: +973 39057428
Complete Address: Building No. 276, Block 320, Flat 71, Road 2007, Al Hoora,
Bahrain
[X] Revocable []Irrevocable

Primary Beneficiary 2
Name : Ryan Rene Peñaflor Advincula
Relationship : Father
Citizenship : Filipino
Birthdate : January 1 1979
Contact No: +973 39479233
Complete Address: Building No. 276, Block 320, Flat 71, Road 2007, Al Hoora,
Bahrain
[X]Revocable []Irrevocable

Primary Beneficiary 3
Name : Zelina Kathryn Del Rosario Advincula
Relationship : Sister
Citizenship : Filipino
Birthdate : August 17 2012
Contact No: N/A
Complete Address: Building No. 276, Block 320, Flat 71, Road 2007, Al Hoora,
Bahrain
[]Revocable [X]Irrevocable

Smoking Habit - Consumed within the last 12 months []Lessthan 5 []5-10 []11-20
[]21-40 []40+ [x]None

Family History :
Father
Living or Deceased?: Living
Age : 44
Health Condition : normal

Mother
Living or Deceased?: Living
Age :51
Health Condition : Operated with hysterectomy around 2017 otherwise in good
condition

Brother/s:
Living or Deceased?: N/A
Age : N/A
Health Condition : N/A

Sister/s
Living or Deceased?: Living
Age : 11
Health Condition : normal

Height : 5’2
Weight : 50