LIST OF ENROLLEES

COOPERATIVE NAME:_FIRST COMMUNITY COOPERATIVE__

NOTE: PLEASE USE ALLCAPS WHEN INPUTTING THE ASSURED DETAILS

Name of Insured
Middle BirthDate (mm/day/yr)
Last Name First Name
Name
1
2
3
4
5
6
7
8
9
10
NITY COOPERATIVE___________________________________________________________

Address
Age Gender Status Number Street,
Barangay
Subd./Village
_______________________

Address BENEFICIARY

City/ Municipality Province SURNAME FIRST NAME

CIARY
BirthDate
CONTACT NO. BRANCH Plan Option
MIDDLE NAME (mm/day/yr)
Effectivity
POC No. Premium
Date

TOTAL: -
 Declaration Form
LIST OF ENROLLEES
COOPERATIVE NAME:

NOTE: PLEASE USE ALLCAPS WHEN INPUTTING THE ASSURED DETAILS

Name of Insured BirthDate

Last Name First Name Middle Name (mm/day/yr)
1 CASTILLANES NORLITA P. 8/17/1966
2 BARBER ROSIE B. 5/29/1966
3 PAGURAYAN MERIZA S. 1/16/1981
4 LAGUINDAB JASMINE MONREAL 5/8/1990
5
6
7
8
9
10
 FIRST COMMUNITY COOPERATIVE

ED DETAILS

Age Gender Status BRANCH Plan Option

55 F MAR KALILANGAN WARD

54 F WID WAO WARD
40 F MAR WAO WARD
31 F MAR WAO WARD
Effectivity Date POLICY NO. Premium

9/8/2021 03-1119-074698 2,700.00

9/8/2021 2,700.00
9/8/2021 03-0218-029583 2,700.00
9/8/2021 03-0717-015079 2,700.00

TOTAL: 10,800.00