Individual Enrollment Form for Group Insurance

Personal Information
Last Name First Name Middle Name
FOR PIONEER LIFE USE ONLY
De Los Santos Inno Nueva
Birthdate (mm/dd/yyyy) Birthplace Age Sex Height Weight Group Policy No.

12/28/1992 Iriga city 30 Male 173 cm Certificate No.

76 kg.
Residence Address Civil Status Nationality Effective Date

89-b Champac St. Western Bicutan, Taguig City Single Filipino

Amount of Insurance:
Contact Number(s) SSS/GSIS Number Tax Identification Number (TIN)
09652779293 34-7692359-8 Basic Life
714-598-469
Name of Employer/Association/Creditor Occupation/Position Accident
TPD
Zachry Philippines Inc. Electrical Designer
Bereavement
Date of Employment/Membership/Loan Term of Loan (if Group Credit Life) Amount of Loan (if Group Credit Life)
Approval (mm/dd/yyyy) Others
04/11/2023 N/A N/A (pls. specify)
Beneficiary Designation
Full Name (Last, First, Middle) of Beneficiary(ies) Birthdate (mm/dd/yyyy) Age Relationship to Insured
Mercedita N. De Los Santos 04/26/1968 55 Mother
Carl N. De Los Santos 01/05/2003 20 Brother

I hereby certify that the personal data contained herein are true and correct.
Digitally signed by Inno N. De Los Santos
DN: C=PH, E=Inno03delossantos@gmail.com, CN=Inno
Inno N. De Los Santos N. De Los Santos
Date: 2023.07.04 14:53:48+08'00'

Signature over printed name of applicant Date (mm/dd/yyyy)

PIONEER LIFE INC.
Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph