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  • Application Form Group/Enhanced Personal Accident Insurance

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    Tsie Rivera
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    This document is an application form for group/enhanced personal accident insurance. It provides details about Richard Quizon Rivera such as his date of birth, contact information, address, beneficiaries, and insurance premium amount. The form lists Richard as the insured person and provides his wife and children as beneficiaries for a 700,000 peso life insurance policy with a 600 peso premium and 12% tax due.

    Original Description:

    GSIS APPLICATION

    Original Title

    GSISAPPLICATION EPAI_612

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    This document is an application form for group/enhanced personal accident insurance. It provides details about Richard Quizon Rivera such as his date of birth, contact information, address, beneficiaries, and insurance premium amount. The form lists Richard as the insured person and provides his wife and children as beneficiaries for a 700,000 peso life insurance policy with a 600 peso premium and 12% tax due.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    399 views1 page

    Application Form Group/Enhanced Personal Accident Insurance

    Uploaded by

    Tsie Rivera
    This document is an application form for group/enhanced personal accident insurance. It provides details about Richard Quizon Rivera such as his date of birth, contact information, address, beneficiaries, and insurance premium amount. The form lists Richard as the insured person and provides his wife and children as beneficiaries for a 700,000 peso life insurance policy with a 600 peso premium and 12% tax due.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    APPLICATION FORM

    GROUP/ENHANCED PERSONAL ACCIDENT INSURANCE

    DATE September 28, 2020

    GSIS Member (Full Name) RICHARD QUIZON RIVERA


    (ACTIVE/PENSIONER/RETIREES) (with Middle name)
    Date of Birth June 07, 1976
    Cellphone No. +63 9428310280 TIN # ###
    Home Address 0231-a Villa Rivera & Jocson Compound, Barangay Mabiga, Mabalacat City
    Landline No.
    Office Address 0255 MacArthur Highway, Mabiga, Mabalacat City, Pampanga
    Tel. No. 045-331-7404 (108)

    ZIP CODe 2010


    Person/Family Members to be Insured Relationship Birthdate Age Profession Beneficiary/ies Amount of Insurance Premium Tax

    1 Richard Q. Rivera Self 6/7/1976 44 Jenny E. David-Rivera 700,000.00 600 12

    2 Kirsten Tsien D. Rivera

    3 Richard D. Rivera II

    10

    Amount Due 612.00

    RICHARD QUIZON RIVERA


    GSIS MEMBER
    Additional Requirements; Signature over Printed Name
    Proof of Relationship

    Marriage Contract

    Birth Certificate

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