Information Sheet for Personal Accident (PA) Age at entry: 18-65yo

PLEASE FILL UP THE FORM COMPLETELY…THANK YOU!

I. A. For the INSURED:

Surname First Name Middle
________________________________________________________________________________

Birthday (mo/day/yr): ____________Birthplace: _________________________ Status: _________

Sex (M/F): _____________ Height: ___________________ Weight: _____________________

Residential Address:_____________________________________________________ Zip code:____

Company: _________________________________________ Position: ________________

Company Address: ______________________________________________________ Zip code:______

B. Beneficiaries of the Insured:

Beneficiaries Relationship to Birthday Age Birth Place
(Surname,Given Middlename) Insured (mo/day/yr)
(1)
(2)

C. Family Details of the Insured:

Family Members Condition/illness Age Cause of Death Age at Death
Father
Mother

Siblings

II. For the POLICY OWNER [Accomplish if different from Insured]:

Surname First Name Middle

_________________________________________________________________________________

Birthday (mo/day/yr): ____________Birthplace: _____________________ Status: _______________

Sex (M/F): _____________ Height: _______________ Weight: _____________________

Residential Address:______________________________________________________ Zip code:____

Landline: _________________ Cell phone#: ____________________ E-mail: ____________________

Office/Company:__________________________________Occupation/Position: ______________________

TIN/SSS/GSIS: ___________________ Nature of Business of Employer:_______________________________

Business/Employer Address: _______________________________________________________________

Gross Annual Income:_____________________ Estimated Net Worth:________________________

Note: Please attach the following photocopies:

1. One (1) VALID ID of the Insured (SSS/GSIS/Any Government ID), and
2. ONE (1) Valid ID of the Policy Owner(If different from Insured)

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Information Sheet for Personal Accident (PA) Age at entry: 18-65yo

Personal Accident Package: (Kindly choose desired package)

Tick Package ADD BB MA TPD HI MR

(Accidental Death & (Burial (Murder & (Total & Permanent (Hospital (Medical
Disability) Benefit) Assault) Disability) R
ei
m
b
ur
se
m
e
nt
)
Package 1 100,000 5,000 50,000 100,000 500 10,000
Package 2 300,000 5,000 150,000 300,000 1,000 30,000
Package 3 500,000 10,000 250,000 500,000 2,000 50,000
Package 4 1,000,000 10,000 500,000 1,000,000 2,000 100,000
Package 5 2,000,000 10,000 1,000,000 2,000,000 2,000 100,000
Premiums *guaranteed for one year only from date of issuance and renewable.
Premium Package 1 Package 2 Package 3 Package 4 Package 5

*Class 1 510.83 1,419.71 2,441.32 4,431.82 6,516.82

*Class 2 615.83 1,692.71 2,924.32 5,229.82 7,944.82

*Class 3 696.18 1,890.41 3,282.72 5,773.22 8,858.22

*Class 4 833.96 2,248.96 3,916.82 6,822.32 10,737.32

Occupational Description Examples

*Class

Class 1 Office type, non-hazardous occupations Office personnel, medical representative, insurance agents, programmers, hairdressers,
teachers, doctors, dentists, cashiers, lawyers

Class 2 Jobs involving limited exposure to occupational Chemist, jewelry merchants, door-to-door salesmen, agricultural technicians, contractors,
hazards(including limited manual labor, but not plant supervisors, tailors/dressmakers(in-shop), architects, engineers doing field work, sari-
using machinery) sari or neighborhood store owners

Class 3 Skilled or semi-skilled occupations, including Warehousemen, electricians/plumbers, auto mechanics, messengers on foot, x-ray
those using light machinery technicians, gas station attendants, local domestic helpers, family drivers

Class 4 Industrial jobs using heavy machinery or Security guards, welders/cutters, truck drivers/helpers, jeepney/taxi drivers, butchers,
unskilled jobs stevedores, outdoor painters, bus drivers/conductors/inspectors, deliverymen(on
bile/motorcycle)

Examples of Unacceptable Occupations

OFWs, sailors, seamen, Politicians, GROs, Offshore and deep sea fishermen, Miners Fire fighters, tricycle drivers, Automotive racing drivers

Professional divers, Construction workers
Private detectives, Personal Bodyguards,
Electrical linemen, Mountain guides
Military men and women
Air transportation workers (pilot or crew or
commercial/non-commercial flights,
test/private/student pilots)
Police and other law enforcers(PNP,NBI, Custom Police or special
agent, motorcycle/harbor police, traffic enforcers, traffic aides)
Professional sportsmen (i.e basketball, boxers, etc.)

For inquiries and clarifications, kindly contact:

ADEL Q. MARFA
Financial Advisor, PRU LIFE U.K.

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Information Sheet for Personal Accident (PA) Age at entry: 18-65yo

CP#+63 917-5251531
Email: plukadelmarfa@gmail.com

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