MEMBER ENROLLMENT FORM

Corporate Solutions

PERSONAL INFORMATION OF THE MEMBER

Organization: Policy Number:

CAFE RAZCHA

Name: Contact Number:

GABRIEL CHARMAINE DUGAY 0921-585-9921 / 09985771026
Last Name First Name Middle Name

Date of Birth (MM / DD / YYYY): Civil Status: Gender: E-mail Address:

1 0 - 2 6 - 1 9 9 7 SINGLE FEMALE [email protected]

Date Hired (MM / DD / YYYY): Designation: Height: Weight:

- -
ft/in kg

DESIGNATION OF BENEFICIARIES

Name of Beneficiary Relationship to Employee % Share of Benefits Irrevocable

N/A Yes

Yes

Yes

Notes:
1. Designation of unlawful spouse as beneficiary is unacceptable.
2. Beneficiary designation is subject to the provisions stated in the Group Master Policy.
3. If the beneficiary listed above passes before the Member, the interest of such beneficiary shall, unless otherwise provided above,
accrue to the surviving beneficiaries, or, if none, to be paid in accordance with the contractual provision.
4. The Member shall have the right to change any beneficiary listed above, unless the beneficiary designation is irrevocable. In which
case, the consent of the irrevocable beneficiary is necessary to effect the change.
5. Use additional sheets if necessary.

ENROLLMENT OF DEPENDENTS

Name of Dependent Relationship to Employee Date of Birth

Notes:
1. Enrollment of Dependents applies to policies with Dependent’s Coverage only.
2. Enrollment of Dependents is subject to the provisions stated in the Group Master Policy.

DECLARATION AND AGREEMENT

1. I request membership in the group insurance for which I am, or may become eligible. I agree, if admitted, to the deduction of the appropriate
contribution from my pay, if applicable, and to produce evidence of age if required.
2. I hereby declare and agree that all statements and answers contained herein are full, complete, and true and that this form shall be part of my
enrolment to Group Insurance.
3. I acknowledge and agree to third party processors required by BPI-Philam Life Assurance Corporation (the Company) in order to maintain
quality, and deliver efficient and effective Services. I also acknowledge and agree to provide my personal identifiable and sensitive information
to the Company for it to provide said Services.
4. I agree and authorize the Company to collect, record, organize, store, update, transfer, use for monitoring and/or audit purposes, and to
process as necessary, any information pertaining to myself/ourselves, this application or insurance policy issued pursuant to it or my/our
existing insurance policies, if any, or any updates thereof under the following circumstances:

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 MEMBER ENROLLMENT FORM
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DECLARATION AND AGREEMENT

a. To provide the Services I requested as stated in the document for the purpose of the policy being issued and administered for benefits
provided as stated in the policy;
b. To upload my/our medical information to a Medical Information 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 the
said medical information in order to protect my/our right to privacy in accordance with the law. A copy of Circular Letter No. 2016-54
may be accessed on the Insurance Commission’s website at www.insurance.gov.ph;
d. To disclose my/our information to the Company’s affiliations (including but not limited to any of its subsidiaries/affiliates or other
related corporations in the Asia Pacific Region), its Brokers, Agents, and their employees and staff and to accredited/affiliated third
parties or independent/non-affiliated third parties, whether local or foreign. In this regard, the Company employs security systems
designed to protect my/our information against unauthorized access;
e. To allow this consent to remain valid from its execution and until 7 years after the termination of my/our individual coverage, or at
such time that I submit to the Company a written revocation/cancellation of such Consent, whichever is earlier; I agree that my/our
information will be deleted/destroyed after this period;
f. To use such information in the design and communication of its customer programs, marketing research, campaigns and offers in
order to improve the quality of service the Company provides. Should I wish not to receive marketing campaigns and offers from the
Company, I will notify the Company by visiting a branch or calling the Company’s contact center.
5. I hereby acknowledge and warrant that I have acquired the consent of all parties pertinent to this transaction to disclose their information for
the proper administration and provision of services requested from this transaction.
6. I hereby hold free and harmless and undertake to indemnify the Company for any complaint, suit, damages and the like which any party may
file or claim against the Company in relation to this declaration and agreement.
7. I acknowledge that I will receive the proof of cover and other correspondence in electronic format via email and/or SMS. I will ensure that the
email address is valid and updated.
8. I further agree that the insurance coverage under this application is based on the truth of the foregoing declarations and representations and
is subject to the provisions of the Group Life Insurance issued by BPI-PHILAM LIFE ASSURANCE CORPORATION to the
aforementioned .

Signature Above Printed Name of Member Date and Place Signed

FRAUD WARNING

Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed or imprisonment of two (2) years, or both,
at the discretion of the court, to any person who presents or causes to be presented any fraudulent claim for the payment of a loss under a contract
of insurance, and who fraudulently prepares, makes or subscribes any writing with intent to present or use the same, or to allow it to be presented
in support of any claim.

IMPORTANT NOTICE

The Insurance Commission, with offices in Manila, Cebu and Davao, is the government office in charge of the enforcement of all laws related to
insurance and has supervision over insurance companies and intermediaries. It is ready at all times to assist the general public in matters
pertaining to insurance. For any inquiries or complaints, please contact the Public Assistance and Mediation Division (PAMD) of the
Insurance Commission at 1071 United Nations Avenue, Manila with telephone numbers to 70 and
email address [email protected]. The official website of the Insurance Commission is www.insurance.gov.ph

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MEMBER ENROLLMENT FORM (EXTRA SHEETS)
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DESIGNATION OF BENEFICIARIES

Name of Beneficiary Relationship to Employee % Share of Benefits Irrevocable

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Notes:
1. Designation of unlawful spouse as beneficiary is unacceptable.
2. Beneficiary designation is subject to the provisions stated in the Group Master Policy.
3. If the beneficiary listed above passes before the Member, the interest of such beneficiary shall, unless otherwise provided above,
accrue to the surviving beneficiaries, or, if none, to be paid in accordance with the contractual provision.
4. The Member shall have the right to change any beneficiary listed above, unless the beneficiary designation is irrevocable. In which
case, the consent of the irrevocable beneficiary is necessary to effect the change.
5. Use additional sheets if necessary.

ENROLLMENT OF DEPENDENTS

Name of Dependent Relationship to Employee Date of Birth

Notes:
1. Enrollment of Dependents applies to policies with Dependent’s Coverage only.
2. Enrollment of Dependents is subject to the provisions stated in the Group Master Policy.

BPI-Philam Customer Extra Sheet

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