Date:

GROUP MARKETING OPERATIONS

Application for Group Yearly Renewable Term (GYRT)

Traditional Referred Request for Franchise Request for Proposal

IMPORTANT REMINDERS:

Granting of Franchise/Issuance of Proposal is not AUTOMATIC. It is dependent on the submission of data required by Group Sales Department (e.g. census list, claims experience, and
if franchise is still open). It is not absolute, meaning it can be rescinded, revoked, or transferred even during the 30 to 60 days franchise period if data submitted is erroneous or if by
client's choice.

REQUEST WILL NOT BE PROCESSED IF INFORMATION BELOW IS INCOMPLETE AND WITH NO SIGNATURES ON THE REQUEST.

I COMPANY INFORMATION: Fo r GMO use o nly:

Group Name O k to Fran ch ise
Address with Existin g Fran ch ise
Contact Person
Position E-mail Address Franchise no : ______
Telephone Nos. Fax No. Date o f Franchise appro val: ____________
Cell No. Industry Expiry o f Franchise: _______________

II DETAILS OF PROPOSAL
With existing provider : Yes, please specify __________________ Renewal Date _________________ Mode of payment: Annual
No Semi-Annual
Payment of premiums: Non-contributory Quarterly
Contributory Monthly
Census list:
Yes (Please send hard and soft copy) None
Number of members to be insured ____________
Eligibility age: Estimated average age of the group ___________
Minimum: ___________ Maximum: ___________
(minimum and maximum Age)
Eligible members: Employees Dependents: Children
Members Parents
Brothers/Sisters

A. SME Plan
Customized Plan Amo unt o f Co verage
Group Yearly Renewable Term (GYRT) Benefits Class 1 Class 2 Class 3 Class 4
GYRT ( Basic Life)
Riders: Riders
Accidental Death and Dismemberment Benefit (ADD) AD D ADD D
Accidental Death, Dismemberment and Disability (ADDD) TPD TPID
Total and Permanent Disability Benefit (TPD) TIB
Total and Permanent Disability Income Benefit (TPID) Ho spital & Surgical
Terminal Illness Benefit (TIB) IN-PATIENT
Hospital & Surgical (H&S) Expense Benefit Room & Board ( per day)
If with H&S Rider, please accomplish details below Special H ospital Services
Surgical Expen se Ben efit
An esth esiologist's Fee
Ph ysician 's Fee ( per day)
B. Other details needed for GYRT with or without Riders: Maxim um Benefit Lim it
O UT-PATIENT
If no existing provider, please indicate amount for consideration: Con sultation Fees
Diagn ostic Lab Test
Non-Medical Limit (NML) : _________________ Prescribed Medicin e
No Evidence Limit (NEL) : _________________
Annual Lim it

Note:
If with existing provider, Agent must show/present proof of the following: existing Underwriting Limits (NML and NEL), claims experience during the last 2 years and latest billing, if none,
the account will categorized as with no existing provider.

C. Additional details needed if with Hospital and Surgical (H&S) Benefit Rider:

Optional Benefits: Maternity Dental Optical

Amount/s of Coverage: ________ Amount/s of Coverage: ________ Amount/s of Coverage: ________
Dental Network: ______________

1 With detailed utilization report: Yes - please send copy by e-mail with existing Schedule of Benefits
None - State reason why: _______________________________________________________

2 With Medical Guarantee Card: Yes (please indicate preferred provider:______________)

In and Out - Patient In-patient only Out-patient only
None
Reimbursement Letter of Authority (LOA)

3 Other instructions being requested by prospective policyholder:

a d
b e
c f

I hereby certify that the above data are correct, and I agree that proposal quoted will be released within 3 to 5 working days.

III SALES AGENT/GSO INFORMATION Compensation:

Agent's Name and Signature Basic Commission: _______% of gross premium
Agent's Code No. ORC: _______ of gross premium
Agency Affiliation/Region
Name and signature of AM/SAM
Name and signature of R.M. Note: Agent with Broker is not allowed.
Broker's Name
 Date:
GROUP MARKETING OPERATIONS
Application for Group Yearly Renewable Term (GYRT)

Agent Broker Direct Referred

Agency Referred RCBC RBG Referred (For SBSO, BSO's)
RCBC CBG Referred (for RM's) YGC Referred

IMPORTANT REMINDERS:

Granting of Franchise/Issuance of Proposal is not AUTOMATIC. It is dependent on the submission of data required by Group Sales Department (e.g. census list, claims experience, and if franchise is
still open). It is not absolute, meaning it can be rescinded, revoked, or transferred even during the 30 to 60 days franchise period if data submitted is erroneous or if by client's choice.

REQUEST WILL NOT BE PROCESSED IF INFORMATION BELOW IS INCOMPLETE AND WITH NO SIGNATURES ON THE REQUEST.

I. COMPANY INFORMATION:
Group Name E. F. CORNEL ELECTRICAL SERVICES Fo r GMO use o nly:
Address 17 PAG-ASA ST., MANDALUYONG CITY; 22 MAAGAP ST., NOVALICHES PROPER, QUEZON CITY Ok to Fran ch ise
Contact Person ANGELO WONG PURA with Existin g Fran ch ise
Position FINANCE E-mail Address sales@efces.com
Telephone Nos. (02)7211 4633 Fax No. N/A D ate o f Franchise appro val: ____________
Cell No. 9176288216 Industry ELECTRICAL SERVICES Expiry o f Franchise: _______________

II. DETAILS OF PROPOSAL

With existing provider : Yes, please specify ________________ Renewal Date ______________ Payment of premiums: Non-contributory
No Contributory

Mode of payment: Annual

Semi-Annual
Quarterly
Monthly

Eligible members: Employees Members Dependents Number of members to be insured ____________

A. SME Plan
Customized Plan Amount of Coverage
Benefits
Group Yearly Renewable Term (GYRT) Option 1 Option 2 Option 3 Option 4
Group Personal Accident Insurance (GPAI) GYRT (Basic Life)
RIDERS GPAI
Accidental Death and Dismemberment Benefit (ADD) RIDERS
Accidental Death, Dismemberment and Disability (ADDD) ADD
Accidental Medical Reimbursement (AMR) ADDD
Family Assistance Benefit (FAB) AMR
Total and Permanent Disability Income Benefit (TPDIB) TPDIB
Terminal Illness Benefit (TIB) TIB
Hospital & Surgical (H&S) Expense Benefit Hospital & Surgical
IN-PATIENT
If with H&S Rider, please accomplish details under item letter "C" Room & Board (per day)
Special Hospital Services
Surgical Expense Benefit
B. Other details needed for GYRT with or without Riders: Anesthesiologist's Fee
Physician's Fee (per day)
If no existing provider, please indicate amount for consideration: Maximum Benefit Limit
OUT-PATIENT
Non-Medical Limit (NML) : ___________________________ Consultation Fees
No Evidence Limit (NEL) : ___________________________ Diagnostic Lab Test
Prescribed Medicine
Annual Limit

Note:
If with existing provider, Agent must show/present proof of the following: existing Underwriting Limits (NML and NEL), claims experience during the last 2 years and latest billing, if none, the account will
be categorized as with no existing provider.

C. Additional details needed if with Hospital and Surgical (H&S) Benefit Rider:

Optional Benefits: Maternity Dental Annual Physical Exam

Amount/s of Coverage: ________

1. With detailed utilization report: Yes - please send copy by e-mail with existing Schedule of Benefits
None - State reason why: _______________________________________________________

2. With Medical Guarantee Card: Yes (please indicate preferred provider:______________)

In-Patient and Out-Patient In-Patient only
None
Reimbursement Letter of Authority (LOA)

I hereby certify that the above data are correct, and I agree that proposal quoted will be released within 3 to 5 working days.

III. SALES AGENT/GSO/BSO INFORMATION

ORC
Name of Agent Agent Code Affi liation/Region Name of AM Name of SAM Basic Commission (%)
AGENCY % Basic Commission

Name of RM Employee Code Area Basic Commission (%)

RCBC-CBG

ORC
Name of BSSO/BSO Agent Code Area Name of Area Manager Name of Region Head Basic Commission (%)
% Basic Commission
RCBC-RBG

BROKER / Contact Person

Name of Broker Agent Code Basic Commission (%)
(if applicable)
PARTNER
AGENCY

SGSO / Name of GSO Agent Code Team Basic Commission (%)

GSO YILE BRYAN M. GARCIA INTERMED-
METSOLUZ