Corporate Bank Information Form (LOCAL)

Entity Information
Complete Name:
Address: Unit No. Building Name No. and Street Name City State/Province/Region Zip/Postal Code Country

Remittance Address (if different from the above address):

Phone Number: Fax Number:

* For multiple entities that use the same banking information, please provide the above information for all entities that use the provided
banking information.

Banking Information
Account Name:
Account Number:
Account Currency:
Bank Name:
Optional (Additional remarks on remittance):
Please attach proof of Bank Account: (Passbook/Picture of Deposit Slip/Bank Statement/Picture of a Bank Certification)

Authorized Representative/s
Individual Name: Department:
Title: Email: Mobile Number:
Individual Name: Department:
Title: Email: Mobile Number:
Individual Name: Department:
Title: Email: Mobile Number:
Please note that future instructions received from non-authorized representatives will not be honored.

Recipient of Payment Advice

Name:
Title: Email: Mobile Number:
Name:
Title: Email: Mobile Number:

PIONEER INSURANCE & SURETY CORPORATION

Pioneer House Makati, 108 Paseo de Roxas, Legazpi Village, Makati City 1229, Philippines
Tel: +63 2 8812 7777 or +63 2 7750 9999 • Fax: +63 2 8817 1461 • www.pioneer.com.ph
I confirm that I am authorized to sign this form and the representatives detailed in this form are authorized to
provide instructions related to banking information. I also confirm my understanding that any changes in the
details in this form will need to be notified to Pioneer Insurance and any changes in authorized representatives
will need to be signed by an authorized signatory.

I further consent to allowing Pioneer Insurance to independently confirm the details reflected in this form.

I agree and consent that, to the extent required by law, Pioneer Insurance may collect, use, and process my
personal information for any of the following purposes, in accordance with the Data Privacy Act of 2012
and Pioneer’s Data Privacy Policy.

• To maintain a bank payment masterfile,

• To facilitate validation of changes to the payment details, and
• To validate payment transactions as needed.

I am aware, have read and understood Pioneer’s Data Privacy Notice.

(link to www.pioneer.com.ph/about-us/data-privacy-notice)

By signing the form, I acknowledge and agree to all of the above terms and conditions.

Signature over Printed Name Title

Email Address Mobile Number

Date