Individual’s Application

for Group Insurance

Please PRINT clearly. In the Philippines, group insurance products are provided by Sun Life of Canada (Philippines), Inc.,
Use BLACK ink. a member of Sun Life Financial group of companies.

In this application, you and your refer to the person being insured, the Individual, while we, us, our
and the Company refer to Sun Life of Canada, (Philippines), Inc.

1 General Information
Relating to Individual
Last Name £
✔ Male £
✔ Mr. £ Miss
CHUA £ Female £ Mrs £ Others, specify
First Name £ Single £
✔ Married £ Widowed
RONALD £ Divorced £ Separated
Middle Name Birthdate (day/month/year) Age (last birthday)
POLINAG
Other Legal Names (a.k.a.) Type of Group Insurance Applied For
£ Term Life £ Personal Accident
Please provide complete Residence Address (no., street, municipality)
address; do not use P.O. box. 1904 G. SILANG ST., NEW CAPITOL ESTATE 1 SUBD., BGY. BATASAN HILLS
City Province Country Zip code
QUEZON CITY METRO MANILA PHILIPPINES 1126
Occupation
PLANT OPERATOR
Name of Employer Date of Membership (day/month/year)
BITUMEN GLOBAL ALLIANZ, INC.
Business Address (no., street, municipality)
DON MARIANO MARCOS AVE., EXTN., BGY. SAN JOSE, RODRIGUEZ
City Province Country Zip code
RIZAL PHILIPPINES
Home Phone Business Phone Cell Phone E-mail Address
9322351 09234278543

Please indicate beside each Beneficiary

named beneficiary if Primary Beneficiary/ies for proceeds as they become due on death
revocable or irrevocable. Name (First Name, MI, Last Name) Date of Birth (day/month/year) Relationship to Individual

If the space provided is JOAN M. CHUA 20 MAY 1991 SPOUSE

insufficient, please use RONAN RENZ CHUA 11 OCTOBER 2014 SON
separate sheet and attach to
the application.

Contingent Beneficiary/ies in event of death of all primary beneficiaries

Name (First Name, MI, Last Name) Date of Birth (day/month/year) Relationship to Individual

FLORDELIZA B. POLINAG 27 AUGUST 1958 MOTHER

ORLANDO P. CHUA 25 JUNE 1957 FATHER

01-GLA-4-004 Page 1 of 2
 2 Signatures
By signing below, you hereby agree that your insurance will become effective in accordance with the
terms of the plan as outlined in the Group Policy provided that you are Actively-At-Work on such
date and the premium corresponding to your insurance coverage has been paid.

Signature of Individual Printed Name

X RONALD P. CHUA

Signature of Witness Printed Name

X RONALD P. CHUA

Place of Signing Date of Signing (day/month/year)

RODRIGUEZ, RIZAL 29 FEBRUARY 2016

3 For Company Use Only

Policy No. Certificate No. Effective Date

01-GLA-4-004 Page 2 of 2