Individual Application

for Group Life Insurance

The Manufacturers Life Insurance Co. (Phils.), Inc. ESP NEL and Below
Head Office: 10th Floor NEX Tower, 6786 Ayala Avenue, Makati City, 1229 Philippines
Customer Care: (02) 884-7000
Domestic Toll-Free: 1-800-1-888-6268
Website: www.manulife.com.ph Email:phcustomercare@manulife.com

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)
Salvador Fritz Aldrian
Date of Birth (YYYY/MM/DD) Sex ✔
[ ] Male Civil ✔
[ ] Single [ ] Married Height [ ] cm Weight [ ] lbs Place of Birth
[ ] Female Status [ ] Separated [ ] Widowed 5'6 ✔[ ] ft/in 69 ✔[ ] kls Manila
Permanent Residence Address (Number, Street, City & Province) Citizenship

8 Filinvest RD Brgy. Batasan Hills Quezon City Zip Code [ 1126 ]

Office Address (Number, Street, City & Province)
West, corner, 3030, 11th Floor, Bonifacio One Technology Tower, Rizal Drive, 1634 31st Street, Self-Declaration Statement
Taguig, Metro Manila Zip Code [ 1634 ] Check the box that applies:
[✔] [ ]
Contact Numbers Residence Office Mobile I acknowledge that I I acknowledge that I am
(specify area code) 09105697876 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
fritz.aldrian1022@gmail.com Customer Service Rep 34-6421213-0 (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
September 9,2023 September 9,2023
Date of Birth Relationship of
Beneficiary/ies Place of Birth Revocable Irrevocable Citizenship
(YYYY/MM/DD) Applicant
Primary [✔] [ ]
Vianca Del Rosario 09/05/1999 Bulacan Filipino Spouse
Contingent [ ] [ ]

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.

Signed at _____________________________________ By _________________________________________________________

Signature of Applicant

September 14, 2023

Date ______________________________________ Fritz Aldrian Salvador
Witness _______________________________________________________
Signature over Printed Name

Form No. GAT005-A (0414)