ANNEX A

Land Bank of the Philippines

MUTUAL AID BENEFIT PROGRAM / LOSS OF LIFE AND DISABILITY BENEFIT PLAN
MEMBERSHIP & DESIGNATION OF DEPENDENTS/ BENEFICIARIES FORM
ID NO: NAME OF EMPLOYEE (Last, First, M.I.) DEPARTMENT/UNIT 1st DAY OF LBP SERVICE:

CIVIL STATUS: [ ] Single

[ ] Solo Parent APPOINTMENT STATUS: [ ] Permanent [ ] Directly-Hired Contractual
[ ] Married
[ ] Widow/Widower [ ] Co-terminus
I. MUTUAL AID BENEFIT PROGRAM: [ ] Initial [ ] Updating [ ] Additional [ ] Substitution
Fund contributions (premium) pooled from this program by the members and their enrollees shall be used to provide
financial assistance to a member in case of death or fire.
NAME OF DEPENDENT / RELATIONSHIP BIRTHDATE PAD/PFD QUALIFIED DEPENDENTS/ BENEFICIARIES
BENEFICIARY (Maximum of 7) ACTION
(Q,D or C)
1. A. For Single employee
- Parents below 60 yrs. old at the time of registration
- Full-blooded unmarried brothers/sisters and less than 21
yrs. old at the time of registration
2. - Unmarried brothers and sisters not gainfully employed
because of physical/mental disability
B. For Married employee
3. - Legitimate spouse
- Legitimate, illegitimate, or legally adopted children;
single and less than 21 yrs. old at the time of registration
4. - Unmarried children not gainfully employed because of
physical /mental disability
C. For Solo Parent employee
- Parents below 60 yrs. old at the time of registration
5. - Legitimate, illegitimate, or legally adopted children;
single and less than 21 yrs. old at the time of registration
- Unmarried children not gainfully employed because of
6. physical /mental disability
D. For Widow/Widower
- Legitimate, illegitimate, or legally adopted children;
7. single and less than 21 yrs. old at the time of registration
- Unmarried children not gainfully employed because of
physical /mental disability

II. LOSS OF LIFE & DISABILITY BENEFIT PLAN: [ ] Initial [ ] Updating [ ] Additional [ ] Substitution
These are funds established to indemnify Landbankers in case of death or disability.
NAME OF DEPENDENT / RELATIONSHIP BIRTHDATE PAD/PFD QUALIFIED DEPENDENTS/ BENEFICIARIES
BENEFICIARY ACTION
(Q, D or C)
PRIMARY BENEFICIARIES A. For Single employee
- PRIMARY- Parents
1. - SECONDARY- Brothers and sisters
2. B. For Married employee
3. - PRIMARY- Legal spouse and children
- SECONDARY- Parents
4.
C. For Solo Parent employee
5. - PRIMARY- Children
6. - SECONDARY- Parents
7.
D. For Widow/Widower
SECONDARY BENEFICIARIES - PRIMARY- Children
1. - SECONDARY- Parents
2.
CERTIFIED CORRECT: VALIDATED BY:

Signature of Employee/Date Head, Personnel Administration Dept. (PAD)

Signature over Printed Name
NOTE: * Attach DULY CERTIFIED TRUE COPY/ies of birth certificate, legal adoption papers, marriage contract and/or any other legal or
identification document showing the name and birthdate of beneficiaries if not yet submitted to PAD
* Misrepresentation and fraudulent information/documents shall be a ground for disciplinary action
LEGEND: ( Q ) Qualified/ Enrolled
( D ) Disqualified (e.g. overage, half-siblings, LBP spouse, member/employee already married (for enrolling siblings and parents)
( C ) Conditional enrollment (e.g. no supporting documents, not certified as true copy, unreadable documents/birth certificate)
NON-SUBMISSION OF THE REQUIRED DOCUMENTS MAY DELAY OR RESULT IN THE DENIAL
OF THE CLAIM OF SAID ENROLLEE
*MABP/LLDBP
v.1. May2019