Republic of the Philippines

GOVERNMENT SERVICE INSURANCE SYSTEM

Cagayan de Oro Branch Office

GROUP PERSONAL ACCIDENT INSURANCE

TUPAD

Name of Office: Department of Labor and Employment- X Tel./Fax. No.: COVER FOR ONE YEAR COMMENCING ON:
Office Address: Monte Carlo Bldg., Phase 1, RER Subd., Kauswagan, email address: FROM TO
APPLICATION IS:
RENEWAL NEW

DATE OF AMOUNT OF
NAME OF ASSURED AGE ADDRESS DESIGNATED BENEFICIARY Relationship to Assured PERIOD OF EMPLOYMENT
BIRTH INSURANCE

1 ACAO, RUBEN LIG-ANG 8/16/1973 41 Manaol, Lagonglong, Mis. Oriental Pastorcita Lig-ang Aunt
2 BUAT, LEOGELYN GABUTAN 3/27/1997 21 Manaol, Lagonglong, Mis. Oriental Leonielle G. Buat Brother
3 CABABAROS, HANNAH JOY GUHITING 12/9/1998 19 Manaol, Lagonglong, Mis. Oriental Harold G. Cababaros Brother
4 CAPITO, ELJANE LADAO 1/18/1984 34 Manaol, Lagonglong, Mis. Oriental Allan G. Capito Husband
5 NABUA, MARICEL P. 2/15/1979 39 Manaol, Lagonglong, Mis. Oriental Pedrita P. Nabua Mother
6 OLIVEROS, AILYN OJARYO 3/8/1992 26 Manaol, Lagonglong, Mis. Oriental Volter A. Pamisa Cousin
7 PADLA, ARNEL LIG-ANG 12/6/1991 26 Manaol, Lagonglong, Mis. Oriental Elezer Padla Father
8 PAMISA, DELIA ANAY 12/20/1974 44 Manaol, Lagonglong, Mis. Oriental Kristia A. Pamisa Daughter
9 PAMISA, ELYN TABANCURA 1/27/1983 35 Manaol, Lagonglong, Mis. Oriental Leonora Pamisa Mother
10 RICARDE, DARWIN NABONG 5/51976 42 Manaol, Lagonglong, Mis. Oriental Jessa M. Buda Cousin
11 SACAY, LINA RICARDE 7/14/1958 60 Manaol, Lagonglong, Mis. Oriental Leonardo Sacay Father
12 SAMONGAN, ANNABELLE BABUYO 8/7/1964 54 Manaol, Lagonglong, Mis. Oriental Angellou M. Samongan Son
13 SAMONGAN, RHEA JEAN LAGO 8/12/1998 20 Manaol, Lagonglong, Mis. Oriental Ryan L. Samongan Brother
14 ABAO, ALLAN 2/20/1976 42 Lumbo, Lagonglong, Mis. Oriental Annaliza Berongoy Cousin
15 ATUP, KEMPEE BALAT 1/1/1998 21 Lumbo, Lagonglong, Mis. Oriental Rita Atup Mother
16 AYOP, JEROME J. 2/9/1991 27 Lumbo, Lagonglong, Mis. Oriental Julia Mae Ayop Daughter
17 AYOP, NOEL 1/9/1966 52 Lumbo, Lagonglong, Mis. Oriental Otelia Ayop Mother
18 BAGONGON, ELSIE ANAYA 8/13/1954 64 Lumbo, Lagonglong, Mis. Oriental Rodelio Bagongon Husband
19 BALABAG, MARICOR B. 2/19/1985 34 Lumbo, Lagonglong, Mis. Oriental Rex Balabag Husband
20 CABLINDA, MARLYN B. 11/17/1966 52 Lumbo, Lagonglong, Mis. Oriental Romy Bana Cousin
21 CAILING, ROSITA B. 8/2/1960 59 Lumbo, Lagonglong, Mis. Oriental Jaime Cailing Husband
22 CAINOY, RAQUEL MAN-ON 5/16/1987 31 Lumbo, Lagonglong, Mis. Oriental Elmer Fabela Cousin
23 FOSTANES, ROSALIE D. 8/31/1975 44 Lumbo, Lagonglong, Mis. Oriental Danilo Fostanes Husband
24 GADIAN, JENNIVER R. 11/5/1992 25 Lumbo, Lagonglong, Mis. Oriental Aiza Gadian Wife
25 GALARCE, ALFE B. 10/6/1974 44 Lumbo, Lagonglong, Mis. Oriental Maria Nilles Cousin
26 GEAGONIA, LEONORA CARACOT 3/15/1989 29 Lumbo, Lagonglong, Mis. Oriental Michael Puertas Cousin
27 VILLIANCIO, MEME CASAS 10/24/1982 37 Lumbo, Lagonglong, Mis. Oriental Jonathan Villancio Husband
28 ZAMBAS, AGUSTIN 8/25/1953 65 Lumbo, Lagonglong, Mis. Oriental Juanita Zambas Wife
29 CABASAGAN, ROLANDO DAGUIT 2/6/1951 67 Kabulawan, Lagonglong, Mis. Oriental Erlinda Cabasagan Wife
30 CACULBA, FREDDIE D 8/12/1980 39 Kabulawan, Lagonglong, Mis. Oriental Zorahayda Caculba Mother
31 CALLO, LANIE T. 2/19/1988 31 Kabulawan, Lagonglong, Mis. Oriental Perla Callo Mother
32 DAGUIT, FELIPE JR. CABUALAN 11/26/1979 38 Kabulawan, Lagonglong, Mis. Oriental Marycar Daguit Wife
33 EDQUILA, MARK ARNEL ADALIM 11/8/1986 31 Kabulawan, Lagonglong, Mis. Oriental Josephine Edquila Wife
34 ESOY, ELSIE LUMBA 6/13/1977 41 Kabulawan, Lagonglong, Mis. Oriental Nancy Tagarda Sister
35 ESPAÑO, ELMER A 3/22/1976 42 Kabulawan, Lagonglong, Mis. Oriental ESPAÑO, MIRAFLOR C WIFE
36 GABUTAN, ALEJANDRO MANGAYAAY 3/17/1973 45 Kabulawan, Lagonglong, Mis. Oriental GABUTAN, NUMERIANA M MOTHER
37 GALLANA, GERALD 2/16/1998 20 Kabulawan, Lagonglong, Mis. Oriental GALLANA, PRINCESS EVAN WIFE
38 GALIETO, RONALD P 7/31/1981 37 Kabulawan, Lagonglong, Mis. Oriental OYAN, MARYAL D WIFE
39 JUMOC, EVANGELINE PINEDA 6/12/1987 31 Kabulawan, Lagonglong, Mis. Oriental JUMOC, VIRGILIO T FATHER
40 MACABECHA, NINO G 7/31/1987 31 Kabulawan, Lagonglong, Mis. Oriental MACABECHA, CINDY A WIFE
41 PACURIBOT, PACITO OBLIOSCA 9/20/1961 57 Kabulawan, Lagonglong, Mis. Oriental PACURIBOT, STEPHANIE GWE DAUGHTER
42 TABAS, RAQUEL GABUTAN 9/29/1984 34 Kabulawan, Lagonglong, Mis. Oriental ADAJAR, REBECCA GABUTAN MOTHER
43 VELARDE, REY STEPHEN CABUGSA 7/10/1997 21 Kabulawan, Lagonglong, Mis. Oriental VELARDE, RIZA C MOTHER
44 ACOSTA, ROGER GONZALES 9/21/1983 35 Gaston, Lagonglong, Mis. Oriental ACOSTA, JACKELOU D WIFE
45 ASIL-OY, JECK RAFAL 7/19/1984 35 Gaston, Lagonglong, Mis. Oriental MAGDALI, LINA COUSIN
46 BAGACO, DANDY A 3/20/1975 44 Gaston, Lagonglong, Mis. Oriental BAGACO, JANICE D WIFE
47 BAGONGON, ROSITA U 12/21/1953 65 Gaston, Lagonglong, Mis. Oriental BAGONGON, AIMEE DAUGHTER
48 BALAT, MICHAEL DAGALA 7/28/1995 24 Gaston, Lagonglong, Mis. Oriental DAHAN, MELODY B COUSIN
49 CAMANIAN, LIEZEL O 10/19/1988 30 Gaston, Lagonglong, Mis. Oriental BACODIO, RONILYN DAUGHTER
50 CAMANIAN, LOVELY ROSE S 3/4/1994 24 Gaston, Lagonglong, Mis. Oriental OBLIOSCA, RAMON JR. BROTHER
51 CORPUZ, JEFFREY DAGUNAN 7/27/1999 20 Gaston, Lagonglong, Mis. Oriental CORPUZ, JOCELYN D MOTHER
52 OCIO, PELARIO K 1/14/1953 66 Gaston, Lagonglong, Mis. Oriental OCIO, GILDA R WIFE
53 RANALAN, ARIEL JR. ZAPORTIZA 7/8/1989 29 Gaston, Lagonglong, Mis. Oriental RANALAN, CHARISS P WIFE
54 SACOTE, BEN SR. R 8/24/1957 62 Gaston, Lagonglong, Mis. Oriental SACOTE, VERGINIA L WIFE
55 SALVALEON, MA. CRISTINA L 2/5/1984 34 Gaston, Lagonglong, Mis. Oriental ZAPORTIZA, ERWIN HUSBAND
56 ZAPORTIZA, HONEY BALANA 11/25/1995 22 Gaston, Lagonglong, Mis. Oriental ZAPORTIZA, EMMA B MOTHER
57 APUGAN, BERBEN V 3/24/1964 54 Banglay, Lagonglong, Mis. Oriental APUGAN, MELODY P WIFE
58 DAQUIO, ZALDY B 10/29/1982 36 Banglay, Lagonglong, Mis. Oriental DAQUIO, REYNA M WIFE
59 HUGAY, GERRY L 3/10/1989 29 Banglay, Lagonglong, Mis. Oriental HUGAY, JULIETA C WIFE
60 LADARAN, JAYPEE ABACAHIN 12/19/1986 33 Banglay, Lagonglong, Mis. Oriental LADARAN, RUBELYN B WIFE
61 MISO, MARVILO L 3/4/1972 46 Banglay, Lagonglong, Mis. Oriental MISO, MECHEL ROSE WIFE
62 TAMSE, ROSE JENE REDONDO 3/1/1992 26 Banglay, Lagonglong, Mis. Oriental TAMSE, ADMER T HUSBAND
63 TORRES, DONARD Q 8/13/1990 28 Banglay, Lagonglong, Mis. Oriental TORRES, DONARD SON
64 TORRES, MIKE MISO 9/19/1997 21 Banglay, Lagonglong, Mis. Oriental QUIZON, HELEN C SISTER
65 TORRES, WINDY C 8/22/1991 27 Banglay, Lagonglong, Mis. Oriental TORRES, GINALIN C WIFE
66 VALMORIA, LUCINO A 9/24/1957 61 Banglay, Lagonglong, Mis. Oriental VALMORIA, IMELDA B WIFE
67 ACAO, CORAPHEL JAMERO 1/6/1983 35 Tabok, Lagonglong, Mis. Oriental ACAO, ROLANDO JR. HUSBAND
68 AGUILAR, VICTOR JAMES GALING 7/25/1992 26 Tabok, Lagonglong, Mis. Oriental AGUILAR, ZUSETTE WIFE
69 BAGONGON, YOLANDA LABADAN 3/22/1962 56 Tabok, Lagonglong, Mis. Oriental OHIMAN, EDWIN SON
70 BANQUERIGO, EUSEBIO ACENAS 4/28/1968 50 Tabok, Lagonglong, Mis. Oriental BONNEL BANQUERIGO BROTHER
71 BASLAO, ISADORA TAPDASAN 4/10/1953 65 Tabok, Lagonglong, Mis. Oriental BASLAO, JOAN DAUGHTER
72 LILOC, GRACE BUNSAY 2/20/1993 26 Tabok, Lagonglong, Mis. Oriental LILOC, BELTSASAR HUSBAND
73 CASTIL, KIM EFFEM MABELIN 11/24/1981 36 Tabok, Lagonglong, Mis. Oriental CASTIL, KEZZIAH NELLY DAUGHTER
74 SORIANO, MARISSA C. 7/1/1986 33 Tabok, Lagonglong, Mis. Oriental CASTIL, JOEY V HUSBAND
75 CASTIL, MERCY BAGONGON 5/7/1973 46 Tabok, Lagonglong, Mis. Oriental CASTIL, AYAZZ FRED M HUSBAND
76 DE LA CRUZ, JERRY LLAGAS 2/5/1972 47 Tabok, Lagonglong, Mis. Oriental RIZZA BALABAT SISTER
77 DEL VALLE, MARIVIC QUIMBO 2/17/1970 49 Tabok, Lagonglong, Mis. Oriental DEL VALLE, ARGER SON
78 LLOREN, APOLINARIO JR. LLAGAS 7/23/1983 35 Tabok, Lagonglong, Mis. Oriental MADEL CABUYAON COUSIN
79 NABONG, LEDDA JOY PAUCHANO 6/6/1982 36 Tabok, Lagonglong, Mis. Oriental NABONG, PETER C HUSBAND
80 PAUCHANO, JONNEL BAGONGON 10/26/1978 44 Tabok, Lagonglong, Mis. Oriental PAUCHANO, MELISSA B WIFE
81 ABOG, ROLAND A 7/7/1984 35 Umagos, Lagonglong, Mis. Oriental ABOG, HAZEL JANE WIFE
82 BLANCA, RANDY C 4/1/1999 20 Umagos, Lagonglong, Mis. Oriental BLANCA, MARCELA MOTHER
83 CAINGLET, MAY FLEUR 5/5/1992 27 Umagos, Lagonglong, Mis. Oriental CAINGLET, EDGARDO FATHER
84 DAMASING, JOHN LORD 11/17/1992 26 Umagos, Lagonglong, Mis. Oriental DAMASING, LEXIS JANE DAUGHTER
85 GONZALES, RONALD T. 7/9/1981 38 Umagos, Lagonglong, Mis. Oriental GONZALES, MARYJOY WIFE
86 LABAJO, MARCELINA 8/22/1953 66 Umagos, Lagonglong, Mis. Oriental LUNA, BABY JANE GRANDDAUGHTER
87 LATOZA, ZWITZY R. 1/17/1996 23 Umagos, Lagonglong, Mis. Oriental LATOZA, GENENEALI SISTER
88 MACUMAO, CLIFFORD A. 5/10/1984 35 Umagos, Lagonglong, Mis. Oriental MACUMAO, MARIVIC WIFE
89 PAHAY, BERNARD 8/15/1990 29 Umagos, Lagonglong, Mis. Oriental PAHAY, REY ANGELO SON
90 VALMORIA, RONDAN G. 5/29/1965 54 Umagos, Lagonglong, Mis. Oriental VALMORIA, ELIZABETH WIFE
91 VALLAR, NESTOR 6/27/1968 51 Umagos, Lagonglong, Mis. Oriental VALLAR, JENET WIFE
92 ABAO, AISA MIGUELA 11/6/1984 34 Poblacion, Lagonglong, Mis. Oriental ABAO, FLORDECAN HUSBAND
93 ACHAS, JEAMWELL 2/5/1988 31 Poblacion, Lagonglong, Mis. Oriental ACHAS, MINAGIL WIFE
94 BAROY, MARITES BALABAG 11/24/1970 48 Poblacion, Lagonglong, Mis. Oriental BAROY, JERRY HUSBAND
95 CABLAY, NHEEPE JHUN 6/10/1991 28 Poblacion, Lagonglong, Mis. Oriental EMERALDA, NANCY SISTER
96 DAGUIT, CRISTALUNA 8/1/1997 22 Poblacion, Lagonglong, Mis. Oriental DAGUIT, CRYSTYLE DAUGHTER
97 DUMDUM, LOLITA OHIMAN 9/3/1980 39 Poblacion, Lagonglong, Mis. Oriental DUMDUM, HIERALD SON
98 EDQUILA, ERA TAHOYNON 7/14/1980 38 Poblacion, Lagonglong, Mis. Oriental CABALTERA, ROWENA NIECE
99 FLORIG, LORNA M 3/16/1967 51 Poblacion, Lagonglong, Mis. Oriental FLORIG, EUSEBIO HUSBAND
100 FORTIM, PAUL NIKKI DAHILAN 9/16/1987 31 Poblacion, Lagonglong, Mis. Oriental FORTIM, TIMYLOU WIFE
101 GABIA, SHIELA MAE 8/25/1997 22 Poblacion, Lagonglong, Mis. Oriental GABIA, EDGARDO FATHER
102 MACION, BENJIE DALAUTA 7/24/1986 32 Poblacion, Lagonglong, Mis. Oriental MACION, GUILLERMA MOTHER
103 MIGUELA, ROSEPHINE 7/15/1966 53 Poblacion, Lagonglong, Mis. Oriental MIGUELA, KATLEIN KET DAUGHTER
104 OHIMAN, JEFFREY BANA 9/1/1994 25 Poblacion, Lagonglong, Mis. Oriental OHIMAN, FE MOTHER
105 TALAO, ROSE DAHILAN 11/22/1972 46 Poblacion, Lagonglong, Mis. Oriental TALAO, JOEL HUSBAND
106 TORAYNO, CHRISTIAN 3/31/1997 22 Poblacion, Lagonglong, Mis. Oriental TORAYNO, CRISOLO FATHER
107 VALLENTE, EDITHA 7/7/1953 66 Poblacion, Lagonglong, Mis. Oriental ABOG, NASH GRANDDAUGHTER
108 ABES, TERESITA CAGADAS 8/23/1966 52 Dampil, Lagonglong, Mis. Oriental ABES, JOE RITO CAGADAS SON
109 ABOGOTAL, MARK ENOPIA 10/23/1986 32 Dampil, Lagonglong, Mis. Oriental ABOGOTAL, NIGEL WIFE
110 ADAJAR, DEBORA JABAGAT 8/13/1991 237.00 Dampil, Lagonglong, Mis. Oriental OMPOC, SYRA DES DAUGHTER
111 ADAJAR, PETERSON SALON 12/7/1990 27 Dampil, Lagonglong, Mis. Oriental ADAJAR, MARINA MOTHER
112 APORDO, DENNIS ORAN 10/24/1977 41 Dampil, Lagonglong, Mis. Oriental APORDO, KHENT GERALD DAL SON
113 CABALIANGA, ISAN TAGAYLO 10/29/1988 30 Dampil, Lagonglong, Mis. Oriental CABALIANGA, DAVELORENZO C HUSBAND
114 DUGO-AN, RAMON TABOR 8/28/1943 76 Dampil, Lagonglong, Mis. Oriental DUGO-AN, GRACIA WIFE
115 NAPOCO, LIZA COCAMAO 10/28/1971 47 Dampil, Lagonglong, Mis. Oriental SILVANO, EASTER GRACE C. DAUGHTER
116 TAGARDA, CRISTIAN GINGCO 10/9/1990 28 Dampil, Lagonglong, Mis. Oriental TAGARDA, RIZA MAE DAUGHTER
117 TINOY, FRATERNIDAD ARES 5/26/1956 62 Dampil, Lagonglong, Mis. Oriental TINOY, REGINO HUSBAND
118 TOR, ARNEL TAGAYLO 6/1/1982 37 Dampil, Lagonglong, Mis. Oriental TOR, JENELYN DAUGHTER
119 AMBACO, MIRRIAM MAESTRE 2/14/1975 43 Kauswagan, Lagonglong, Mis Oriental AMBACO, BENJAMIN HUSBAND
120 MACARAYA, NORA BALABA 10/24/1971 47 Kauswagan, Lagonglong, Mis Oriental MACARAYA, AIAN SON
121 CAGUCO, LIBEE S 3/5/1972 46 Kauswagan, Lagonglong, Mis Oriental CAGUCO, ALBINO SR FATHER
122 GUMAHIN, VICTOR E. 9/16/1978 40 Kauswagan, Lagonglong, Mis Oriental GUMAHIN, AILYN WIFE
123 LIG-ANG, ALICIA LADRA 8/28/1957 61 Kauswagan, Lagonglong, Mis Oriental LIG-ANG ANNE DAUGHTER
124 MABELIN, ANABEL S 4/1/1979 40 Kauswagan, Lagonglong, Mis Oriental MABELIN, ROLDAN HUSBAND
125 SACOTE, JULIE ABAO 7/8/1982 36 Kauswagan, Lagonglong, Mis. Oriental SACOTE, GWYNNES DAUGHTER
126 TADO, KHRYSHEL JEAN V 4/16/1995 23 Kauswagan, Lagonglong, Mis. Oriental TADO, CHRISTOPHER SON
127 WAHIMAN, LAARNE A 9/14/1974 44 Kauswagan, Lagonglong, Mis. Oriental GANZAN, MA. PRECIOUS DAUGHTER
128 WAHIMAN, LEBBRA ACENAS 6/11/1987 31 Kauswagan, Lagonglong, Mis. Oriental WAHIMAN, PRINCEYORI DAUGHTER

I HEREBY DECLARE THAT THE INFORMATION STATED ABOVE ARE IN EVERY RESPECT, CORRECT AND TRUE.
IT IS FURTHER AGREED THAT THIS DECLARATION SHALL BE THE BASIS OF THE CONTRACT OF INSURANCE BETWEEN THE ASSURED AND GSIS.

PREPARED BY: CERTIFIED CORRECT:

JOANNE V. AMORA JOSE ERROL A. NATIVIDAD

Designation:_LEO II__ Designation:_Provincial Head__

What does the GPAI cover?

a) Death
b) Dismemberment & Loss of Sight Indemnity
c) Permanent Total Disability
d) Medical Reimbursement