Application Form - New Financial Plan

CARITAS FINANCIAL PLANS, INC.
PENSION PLAN APPLICATION

I hereby apply to purchase from CARITAS FINANCIAL PLANS, INC. a Pension Plan in accordance with the data set forth in this application and hereby certify that
the data and other information stated herein are written by me or under my direction.
PLANHOLDER INFORMATION
Personal Data
PLANHOLDER (Last Name, First Name, Middle Name)
Age Birthdate Birth Place Gender Civil Status

Male Female Single Married Separated
Nationality ACR# TIN GSIS/SSS #
SPOUSE’S MARRIED NAME (Last Name, First Name, Middle Name)
Residence & Contact Information

Address Telephone No. Mobile Phone No.
Email Address
Source of Income
Please specify nature if source of income is either business or others.
Employment Business Others
Employment / Business
Name of Company Address
Telephone No. Fax No.
Nature of Business Position / Title No. of years with the Company
PLAN DATA
Plan Name (Please check) No. of Units Pension Maturity Benefit Contract Price
The New Fund Provider

Paying Period Maturity Period Mode of Payment
 Classic  Ultima  Ultima Plus
Fund Provider Elite No. of Installments Installment Amount Amount of First Payment
 Plan A  Plan B  Plan C  Plan D
Others (Please specify) : ______________________ With Insurance Benefit (WIB) No Insurance Benefit (NIB)
Beneficiary
PENSION BENEFIT: (Last Name, First Name, Middle Initial) Age Birthdate Relation to Planholder
INSURANCE BENEFITS: If beneficiary is the same as designated under Pension Benefits, please check box and leave the spaces blank. Age Birthdate Relation to Planholder
(Last Name, First Name, Middle Initial)
TRUSTEE if beneficiary is less than 18 years of age (Last Name, First Name, Middle Initial) Age Birthdate Relation to Beneficiary
This Pension Plan Application, with the information and data supplied above, and the declaration and representations given on the reverse side shall be the
basis of the contract between CARITAS FINANCIAL PLANS, INC. and myself, and shall be deemed a part thereof.
I agree that no binding agreement is created by the mere signing of this application until it is accepted and approved by CARITAS FINANCIAL PLANS, INC.
and until the Pension Plan Agreement containing the Contract Provisions signed by the duly authorized officials of CARITAS FINANCIAL PLANS, INC. is
issued to me.
Signature over Printed Name of Applicant/Planholder Signature over Printed Name of Parent/Guardian
(if applicant is below 18 years of age)
Signature over Printed Name of Sales Counselor/Witness Signature over Printed Name of Sales Counselor/Witness
Agency Group SC Code Agency Group SC Code
Head Office Use PPA No.

O.R. Date O.R. No. O.R. Amount Reviewed by:
DECLARATIONS & REPRESENTATIONS
(For applicants 18 - 60 years of age, and in good health.)
For insurance purposes, I hereby represent and declare to the best of my knowledge that:
1. I am not less than 18 years or more than 60 years and 6 months of age at my nearest birthday.
2. I have not been confined in any hospital, sanitarium or infirmary, nor received medical or surgical treatment in the last 12
months.
3. I have not been treated for heart condition, high blood pressure, cancer, diabetes, lung, kidney or stomach disorder or any
other physical or mental impairment in the last five (5) years.
4. I am in good physical and mental condition.
If the statements above reveal otherwise, please give details below. Write “N.A.” if not applicable.
Date of Latest Confinement/Check-up Name of Hospital/Clinic
Name of Attending Physician
Findings:
I understand and agree that the insurance coverage under the Pension Plan applied hereof is based on the truth of the foregoing
declarations and representations and is subject to the provisions of the Group Insurance Master Policy issued by the insuring
company to CARITAS FINANCIAL PLANS, INC.
I likewise understand and agree that, upon the Company’s verification of the above declarations and representations, SHOULD I
BE FOUND NOT QUALIFIED FOR INSURANCE COVERAGE FOR FAILURE TO MEET AGE, HEALTH, AND OTHER
UNDERWRITING REQUIREMENTS, THE PENSION PLAN APPLIED HEREOF SHALL BE ISSUED ON A NO INSURANCE
BENEFIT (NIB) BASIS.
Should the amount of each insurance benefit under the Pension Plan applied hereof and under any other Caritas Financial
Plan’s pre-need agreement issued in my name exceed the prescribed maximum non-medical insurance amount of
P1,500,000.00, I shall be willing to undergo any medical examination as shall be required by the insurance company as basis of
my coverage. Otherwise, I understand and agree that all of my subscriptions in excess of said amount shall be without insurance
coverage.
Witness my hand this ______ day of ______________________, 20_____ at ___________________________________,

Philippines.
Applicant / Planholder Parent / Guardian

(Signature over Printed Name) if applicant is below 18 years of age
(Signature over Printed Name)
Sales Counselor / Witness Sales Counselor / Witness

(Signature over Printed Name) (Signature over Printed Name)
Agency Group SC Code Agency Group SC Code

Application Form - New Financial Plan

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CARITAS FINANCIAL PLANS, INC.

PENSION PLAN APPLICATION

Age Birthdate Birth Place Gender Civil Status

SPOUSE’S MARRIED NAME (Last Name, First Name, Middle Name)

Residence & Contact Information

Telephone No. Fax No.

Nature of Business Position / Title No. of years with the Company

The New Fund Provider

Head Office Use PPA No.

Name of Attending Physician

Witness my hand this day of ______________, 20_ at _________________________________,

Applicant / Planholder Parent / Guardian

Sales Counselor / Witness Sales Counselor / Witness

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