GROUP ENROLLMENT CARD ‘Corporate Soltions: Paty ibe Fst hiame Middle Name ‘Chl States ‘Gender Designation Monty Salary Designation of Beneficiaries (Applies to Group Life Insurance only) ane of Genatcares Ralalorsip wo Employes “Share of Bones Dae of "Nk sition oT ar iT poe ws Bae Ra WBS PEE, request mamtersip in tbe croup pans inca above fr uhich | an, er may become, ely, | agree, mite, tothe dedueson of the aperorate ‘contioulon fom my pay ad to prosuce ewcerce of age requred. hereby deci ha al slateeras and af answers tothe questons on his page are ‘complete andre omy knowledge Ihe Benen ted above ds before me, he inerests of such benetciay shal urtess oeruse provided above, accu othe sung benefiares, 6, nano, to be pad in accrdance wlth the conzacualprodslonIresewe Me gi to change ary benetayIsted above. Signa ol Erayee Dale Pease reer to back page fr Enrollment of Dependent, applicable. QR-CRS-GEC / REVISION 4 / SEPTEMBER 2012 PHILAM LIFE CUSTOMER CONFIDENTIAL, GROUP ENROLLMENT CARD ‘Corporate Soltions: Paty ibe LastName Fst hiame Middle Name Date of ith ‘Chl States ‘Gender Dato Emo; Designation Monty Salary Designation of Beneficiaries (Applies to Group Life Insurance only) ane of Genatcares Ralalorsip wo Employes “Share of Bones Dae of "Nk sition oT ar iT poe ws Bae Ra WBS PEE, request mamtersip in tbe croup pans inca above fr uhich | an, er may become, ely, | agree, mite, tothe dedueson of the aperorate ‘contioulon fom my pay ad to prosuce ewcerce of age requred. hereby deci ha al slateeras and af answers tothe questons on his page are ‘complete andre omy knowledge Ihe Benen ted above ds before me, he inerests of such benetciay shal urtess oeruse provided above, accu othe sung benefiares, 6, nano, to be pad in accrdance wlth the conzacualprodslonIresewe Me gi to change ary benetayIsted above. Signa ol Erayee Dale Pease reer to back page fr Enrollment of Dependent, applicable. QR-CRS-GEC / REVISION 4 / SEPTEMBER 2012 PHILAM LIFE CUSTOMER CONFIDENTIAL,