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    LS - GCL - Individual Above NEL Form - Fillable

    Uploaded by

    Jerald Peter Vargas
    This document is an application for group credit life insurance. It requests information from the proposed insured such as name, date of birth, contact details, occupation, health history, and beneficiary details. The applicant must disclose any pre-existing medical conditions or health issues and provide consent for the insurance company to collect medical information about them. It explains that the insurance policy will be based on the accuracy of the information provided and subjects the applicant to the terms of the group insurance master policy. The applicant's signature is required to authorize the insurance company to collect their health information and process the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    LS - GCL - Individual Above NEL Form - Fillable

    Uploaded by

    Jerald Peter Vargas
    91 views1 page
    This document is an application for group credit life insurance. It requests information from the proposed insured such as name, date of birth, contact details, occupation, health history, and beneficiary details. The applicant must disclose any pre-existing medical conditions or health issues and provide consent for the insurance company to collect medical information about them. It explains that the insurance policy will be based on the accuracy of the information provided and subjects the applicant to the terms of the group insurance master policy. The applicant's signature is required to authorize the insurance company to collect their health information and process the application.

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    LS_GCL_Individual Above NEL Form_Fillable (1) (2)

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    This document is an application for group credit life insurance. It requests information from the proposed insured such as name, date of birth, contact details, occupation, health history, and beneficiary details. The applicant must disclose any pre-existing medical conditions or health issues and provide consent for the insurance company to collect medical information about them. It explains that the insurance policy will be based on the accuracy of the information provided and subjects the applicant to the terms of the group insurance master policy. The applicant's signature is required to authorize the insurance company to collect their health information and process the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    91 views1 page

    LS - GCL - Individual Above NEL Form - Fillable

    Uploaded by

    Jerald Peter Vargas
    This document is an application for group credit life insurance. It requests information from the proposed insured such as name, date of birth, contact details, occupation, health history, and beneficiary details. The applicant must disclose any pre-existing medical conditions or health issues and provide consent for the insurance company to collect medical information about them. It explains that the insurance policy will be based on the accuracy of the information provided and subjects the applicant to the terms of the group insurance master policy. The applicant's signature is required to authorize the insurance company to collect their health information and process the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Individual Application

    for Group Credit Life Insurance


    The Manufacturers Life Insurance Co. (Phils.), Inc. MGCL No
    Head Office: 10th Floor NEX Tower, 6786 Ayala Avenue, Makati City, 1229 Philippines
    Customer Care: (02) 884-7000
    Domestic Toll-Free: 1-800-1-888-6268
    Website: www.manulife.com.ph Email:phcustomercare@manulife.com

    Please answer completely and accurately. If possible use black ink. Any change should be initialled by proposed insured and/or owner/payor.
    Policyholder [ ] Principal Borrower
    [ ] Co-Borrower
    PROPOSED INSURED’S INFORMATION
    Name (Title) (Last) (First) (Middle)

    Date of Birth (YYYY/MM/DD) Sex [ ] Male Civil [ ] Single [ ] Married Height [ ] cm Weight [ ] lbs Place of Birth
    [ ] Female Status [ ] Separated [ ] Widowed [ ] ft/in [ ] kls

    Permanent Residence Address (Number, Street, City & Province) Citizenship

    Zip Code [ ]
    Office Address (Number, Street, City & Province)
    Self-Declaration Statement
    Zip Code [ ] Check the box that applies:
    [ ] [ ]
    Contact Numbers Residence Office Mobile I acknowledge that I I acknowledge that I am
    (specify area code) am not a United States a United States Citizen,
    Citizen, United States United States Permanent
    Email Occupation TIN or SSS/GSIS Permanent Resident Alien Resident Alien (Green
    (Green Card Holder) or a Card Holder) or a United
    United States Resident. States Resident.
    Amount of Loan Term of Loan Maturity Date

    STATEMENT OF HEALTH (Please use back portion if spaces provided below are not sufficient)
    1 Have you ever been declined, postponed, charged higher than standard premium rates, or offered modified benefits for life, critical [ ] Yes [ ] No
    illness, disability, or health insurance?
    2 Have you ever had, been told that you have, had symptoms of or been treated for cancer, growth of any kind, diabetes, raised blood [ ] Yes [ ] No
    pressure, chest pain, heart attack, stroke, Transient Ischemic Attack (TIA), Hepatitis B or C (including Hepatitis B carrier), mental
    illness, rheumatoid arthritis, HIV or AIDS, alcoholism and/or drug addiction, any disease or disorder of the heart, arteries, or veins,
    brain or nervous system, lungs, blood, kidney(s), liver, bowel, stomach, pancreas, or any other major illness or disorder?
    3 During the past 5 years, have you attended or are you currently attending or do you plan to attend any hospital, clinic, or doctor for [ ] Yes [ ] No
    any illness or injury, medical advice, operation, or treatment and/or for any diagnostic test (e.g. ECG, Xray, blood test, etc.) not men-
    tioned, (exclude minor ailments like common colds, flu, minor accidental injuries which you have recovered, routine health check up
    with normal results) and/or are you taking medication on a regular or ongoing basis?
    4 Do you currently have any signs or symptoms of illness or disease for which you have not sought medical advice? [ ] Yes [ ] No
    • Heart disease, stroke, elevated blood pressure, chest pain or other cardiovascular diseases?
    • Cancer, leukemia, Hodgkin’s disease, tumor or other malignancies?
    Please use space provided to provide full details on any “YES” answers to questions #s 1 to 4

    5 Do you engage in aviation, racing (automobile, go-kart, cycle, boat or snowmobile), or diving (skiing, scuba or sky) activities? [ ] Yes [ ] No
    If yes, please give details as to type, location and frequency:

    6 Secondary Beneficiary Date of Birth Revocable Irrevocable Citizenship Relationship to Applicant:


    (YYYY/MM/DD)
    [ ] [ ]

    PRIVACY CONSENT STATEMENT


    We, Manulife Philippines (the Company), value and protect our clients’ privacy as we understand that the use of your personal information is important to you.
    The collection and use of information is fundamental to our business as it allows us to evaluate, issue and administer the policy you have applied for.

    By signing below and submitting this application, you agree that:

    • You understand that the Company is a member company of the Manulife Financial 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 from time to time relating to information sharing and tax reporting from time to time (“regulatory and legal requirements”).
    • You consent to the use of information provided to the Company and you will provide us with information that we request from time to time and allow
    us to share/report such information with our local and foreign authorities (including local and foreign tax authorities) to meet said regulatory and legal
    requirement.
    • You will notify us as soon as possible of any change in the information that you have provided to us, including any circumstances such as a change in
    your residence, address, telephone number and citizenship.
    • You hereby waive any rights you may have that would prevent us from meeting reporting requirement mentioned above.

    I declare that I have not reached ____ years of age. I possess sound health and am able to perform the normal activities in the pursuit of my livelihood. I
    understand and agree that the insurance issued on this application is based on the truth of the foregoing representations and is subject to the provisions of the
    GROUP CREDIT LIFE INSURANCE MASTER POLICY issued by The Manufacturers Life Insurance Company who reserves the right to reject the application
    or rescind the insurance if there was failure on my part, whether intentional or unintentional, to disclose material information pertinent to the insurance applied
    for.

    I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, the Medical
    Information Bureau, my employer, or other organization, institution or person, that has any knowledge of me or my health, to give The Manufacturers Life Insur-
    ance Company any such information. A photographic copy of this authorization shall be as valid as the original.

    Signature of Applicant: _______________________________ Date_____________ Place of Signing __________________

    _________________________________________________
    Witness (Signature over printed name) :

    Form No. MGCL01 (0414)

    Clear Form

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