ST. PETER LIFE PLAN, INC.

999 EDSA, QUEZON CITY,1101

PLANHOLDER'S INFORMATION SHEET
SAN FERNANDO BRANCH

PLAN TYPE CONTRACT

PRICE
ST. ANNE ST. BERNADETTE ST. CLAIRE
TOTAL AMNT. PAYABLE
ST. GREGORY ST. GEORGE

Mode of Payment Spotcash INSURABLE Installment Due:

Annual Semi-Annual Terms ____ Year(s) NON - INSURABLE
Quarterly Monthly
PERSONAL DATA:
NAME: __GONZALES_______________RODEL JOHN___JR__________MANLAPAZ_________
(Surname) (First Name) (Middle Name)
ADDRESS: BLK9 LOT 6B SAPPHIRE HOME SAN JOSE PLARIDEL BULACAN
(Lot #) (Street) (Brgy/Subd) (Municipality) (Province) (Zip Code)

CONTACT NO. 09993553281 DATE OF BIRTH: MAY 20 1994 PLACE OF BIRTH: PLARIDEL AGE: 26
SEX: Male Female HEIGHT: 176cm WEIGHT: 80kg
CIVIL STATUS: Married Single Widow/er Separated/Divorced/Annulled
OCCUPATION: OFW TIN: 453502422000
NAME OF EMPLOYER: AQUALINK MARITIME INC. SSS: 3447886952
BENEFICIARIES:
Principal:
Name Age Address Relationship to Planholder
(Last Name, First Name, M.I)
1. GONZALES, RODELIO, M 61 san jose plaridel bul Father
2. GONZALES, JOSEPHINE, M 55 san jose plaridel bul. Mother
3. GONZALES, JASON, M 34 san jose plaridel bul Brother
Contingent
1. GONZALES, DEXTER, M 30 San jose plaridel bul brother
2. GONZALES, JEANNIFER, M 28 san jose plaridel bul brother

_____________________ ______________________
Family Counselor Signature of Applicant