Sunlife Grepa Application Form

Individual’s Application
for Group Insurance

In the Philippines, this group insurance product is provided by Sun Life Grepa Financial Inc., a joint venture of Sun Life Financial and the
Yuchengco Group of Companies.
In this application, you and your refer to the person being insured, the Individual, while we, us, our and the Company refer to Sun Life Grepa
Financial, Inc.
Sun Life Grepa Financial, Inc. is a Covered Institution under Republic Act No. 9160, as amended, otherwise known as the Anti-Money
Laundering Act of 2001.
Please PRINT clearly. Use BLACK ink.
1 General Information
Relating to Individual
Last Name Male Mr. Miss
Female Mrs. Others, specify
First Name Single Married Widowed
Divorced Separated
Middle Name Birthdate (Month/Day/Year) Age (last birthday)
Other Legal Names (a.k.a.) Birthplace Nationality

Filipino Others, specify
Type of Group Insurance Applied For
Term Life Personal Accident Hospitalization and Surgical Expense
Residence Address (no., street, municipality/city, province, country, zip code ) P.O. Box is not acceptable
Occupation Basic Salary
Name of Employer Date Employed (Month/Day/Year)
Business Address (building, no., street, municipality/city, province, country, zip code) P.O. Box is not acceptable
Beneficiary
Primary Beneficiary/ies for proceeds as they become due on death
Name (First Name, MI, Last Name) Date of Birth (Month/Day/Year) Relationship to Employee
Contingent Beneficiary/ies in event of death of all primary beneficiaries

Name (First Name, MI, Last Name) Date of Birth (Month/Day/Year) Relationship to Employee
Relating to Individual’s Dependents (for Hospitalization and Surgical Expense Benefit only)
Name (First Name, MI, Last Name) Date of Birth (Month/Day/Year) Age Relationship to the Applicant
2 Policy Information
Benefits Requested
RIAG.02.15 *RIAG.02.15* Page 1 of 2

3 Declarations and Representations
1. Within the last 2 years, have any of your applications for insurance been declined, postponed, withdrawn or
accepted on a basis other than that applied for? No Yes
2. Have you had any symptoms of, sought advice for, or been treated for high blood pressure, stroke, heart trouble,
diabetes, cancer or tumor, chest pain, bleeding from the bowel, or blood in your sputum, or has treatment for any
of these been recommended by a physician or other practitioner? No Yes
3. Within the last five years, have you been admitted or been advised to be admitted as an in-patient to a hospital
or clinic EXCEPT for pregnancy, birth, routine health check up, gall bladder/kidney stones, colds, flu/influenza,
gastroenteritis, upper and lower respiratory tract infections, hepatitis A, appendectomy, tonsillectomy,
hemorrhoidectomy, cholecystectomy and herniotomy? No Yes
4. Do you have any health symptoms or complaints for which a physician has not been consulted or treatment has
not been received? For example, persistent fever, unexplained weight loss, loss of appetite, pain or swelling, etc.? No Yes
Give full details of all “Yes” answers in the space provided for:(use a separate sheet if necessary)
Name & Address of
Doctor, Laboratory or Medication, Advice or
Question Date Reason for Visit/Check-up Hospital Treatment Results
4 Signatures
By signing below, you hereby agree that your insurance will become effective in accordance with the terms of the plan as outlined in the Group
Policy provided that you are Actively-At-Work on such date and the premium corresponding to your insurance coverage has been paid.
You expressly authorize the collection, processing, use, storage and destruction of your personal and sensitive personal information and any
information related to your application and/or insurance policy as well as its sharing, transfer and or disclosure to any of the Company’s branches,
subsidiaries, affiliates, agents and representatives, industry associations and third parties such as but not limited to outsourced service providers,
external auditors, and local and foreign regulatory authorities in relation to any matter including but not limited to those involving anti-money
laundering and tax monitoring, review and reporting, statistical and risk analysis, provision of any products, service, or offers made through
mail/email/fax/SMS/telephone, customer satisfaction surveys; compliance with court and other lawful orders and requirements.
You hold the Company free and harmless from any liability that may arise from any transfer, disclosure, processing, collection, use, storage or
destruction of said information.
Signature of Individual Printed Name
X
Signature of Witness Printed Name
X
Place of Signing Date of Signing (day/month/year)
5 For Company Use Only

Policy No. Certificate No. Effective Date
Authorization
By signing below, you authorize that your personal information regarding your health, personal and medical history may be provided to
Sun Life Grepa Financial, Inc. by any organization, institution or person. A copy of this authorization will be as valid as the original.
Signature of Individual Printed Name Date (day/month/year)
X
Signature of Witness Printed Name Date (day/month/year)
X
RIAG.02.15 Page 2 of 2

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Individual’s Application

for Group Insurance

Other Legal Names (a.k.a.) Birthplace Nationality

Occupation Basic Salary

Name of Employer Date Employed (Month/Day/Year)

Contingent Beneficiary/ies in event of death of all primary beneficiaries

RIAG.02.15 RIAG.02.15 Page 1 of 2

5 For Company Use Only

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