Generali Life Assurance Philippines, Inc.

10th Floor Petron Mega Plaza

358 Sen. Gil J. Puyat Ave., Makati City
1209 Philippines
T +632 8888 0808 / F +632 8868 3388
TIN 203-028-895-000
www.generali.com.ph

INDIVIDUAL APPLICATION FORM

In the Philippines, group insurance products and medical benefits are provided by Generali Life Assurance Philippines, Inc. (“GLAPI”), a wholly owned
subsidiary of the Generali Group.
General Instruction: Kindly fill out all the information needed, when applicable, using Black or Blue ink only.
Last Name First Name Middle Name Membership as a ☐ Principal
☐ Dependent
If a Dependent, indicate the name of
Principal:
___________________________

Residence Address (Street No.) (Brgy.)

(City/Municipality) (Province) (Country) (Zip Code)

Contact Details: Home Office Cell Phone Fax

Date of Birth (DD/MM/YYYY) Place of Birth Age Sex Height Weight

☐ Male
☐ Female
Nationality Citizenship Occupation

Source of Fund/Wealth SSS/GSIS/TIN/Phil I.D. :

Others (Please specify) :
Name of Employer Nature of Business

Business Address Email Address

Occupation: Date Employed (DD/MM/YYYY):

This portion is applicable for Credit Life coverage only

Loan Amount Loan Term

NAME OF BENEFICIARY DATE OF BIRTH CITIZENSHIP RELATIONSHIP

(First Name, M.I., Last Name)

I, the proposed life insured individual, declare under the penalty of perjury that to the best of my knowledge and belief the above answers and
statements are true, complete and correctly recorded; and agree that, this application, if approved while I am alive and actively at work or
actively engaged in the exercise of my occupation, and in good health, with the answers given in any other declaration which may be required
by Generali Life Assurance Philippines, Inc. (GLAPI) and which relates to the insurability of the proposed life insured individual or to change
of this policy coverage, shall be the basis for delivery, change or reinstatement of insurance coverage.

By signing below, I agree that:

1. I understand that the GLAPI is a member of Generali 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 relating to information sharing and tax reporting from time to time (“regulatory and legal requirements”).

“DISCLOSURE: ln accordance with the lnsurance Commission's Circular Letter No. 2016-54 your medical information will be uploaded to a Medical
lnformation Database accessible to life insurance companies for the purpose of enhancing risk assessment and preventing fraud.
Once uploaded, all life insurance companies will only have limited access to your information in order to protect your right to privacy in accordance with law.
A copy of Circular Letter 2016-54 may be accessed at the lnsurance Commission's website at www.insurance.gov.ph”
 Generali Life Assurance Philippines, Inc.
10th Floor Petron Mega Plaza
358 Sen. Gil J. Puyat Ave., Makati City
1209 Philippines
T +632 8888 0808 / F +632 8868 3388
TIN 203-028-895-000
www.generali.com.ph
2. All material facts, being facts which might influence the assessment of this Application, have been truthfully, completely and
correctly disclosed in this Application and/or any other declaration which may be required by GLAPI, it being understood that my
failure to make such disclosure renders the contract void.
3. I consent to the collection, processing, use and storage of information provided to GLAPI and I will provide the information they will
request from time to time and allow them to share/report such information with their local and foreign authorities (including local
and foreign tax authorities) to meet said regulatory and legal requirement as well as accredited third party service provider for the
execution of the Policy Contract and its supplementary benefits. All medical information given will be uploaded to a medical
information database accessible to all insurance companies for the purpose of enhancing risk assessment and preventing fraud.
4. I will notify GLAPI as soon as possible of any change in the information that I have provided to them, including any circumstances
such as a change in my residence, address, telephone number and citizenship.
5. I hereby waive any rights I may have that would prevent GLAPI from meeting reporting requirement mentioned above.
6. GLAPI reserves the right to deny claims on the basis of gross fraud or valid grounds recognized under the laws and settled
jurisprudence in case of death in any year.
7. During the effectivity of the of the contract policy, the customer/client agrees to the following:
a. measures to restrict the services available or prohibit any further transaction on the contract/policy until full/proper CDD measures
have been successfully conducted and;
b. in case the foregoing is unsuccessful, terminate business relationship. The exercise of the Company of this measure shall only
entitle customer/client to receive the unused portion of premiums or withdrawal value, if any, whichever is applicable.

SIGNED AT __________________________________________________ON_________________________________________

___________________________________________________ ________________________________________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
OF WITNESS OF PROPOSED INSURED / DEBTOR

“DISCLOSURE: ln accordance with the lnsurance Commission's Circular Letter No. 2016-54 your medical information will be uploaded to a Medical
lnformation Database accessible to life insurance companies for the purpose of enhancing risk assessment and preventing fraud.
Once uploaded, all life insurance companies will only have limited access to your information in order to protect your right to privacy in accordance with law.
A copy of Circular Letter 2016-54 may be accessed at the lnsurance Commission's website at www.insurance.gov.ph”