MIGRANT WORKER’S APPLICATION FOR INSURANCE

PERSONAL INFORMATION/PERSONAL NA IMPORMASYON

Last Name (Apelyido) First Name (Pangalan) Middle Name (Gitnang Pangalan)

Date of Birth (Petsa ng Kapanganakan) Birthplace (Lugar ng Age (Edad) Sex (Kasarian) Civil Status (Katayuang Sibil)
Kapanganakan)
MM DD YYYY Male Female Single Married
/ /

Residence Address (Tirahan)

Occupation (Trabaho) Mobile No. / Landline No. Email Address OFW Card No.

OVERSEAS EMPLOYER/KUMPANYANG PAGTA-TRABAHUHAN

Company Name (Pangalan ng Kumpanya) City and Country of Destination (Lungsod at Bansa)

Business Address (Lugar ng Kumpanya) Name of Vessel (Pangalan ng Barko)

BENEFICIARIES/MGA KAANAK NA TATANGGAP NG BENEPISYO

Indicate whether the beneficiary
Date of Birth Age Email Relationship to the is Revocable or Irrevocable
Full Name (Buong Pangalan) (Araw ng Mobile No. Proposed Insured (Itanda kung ang kaanak na tatanggap
Kapanganakan) (Edad) Address (Relasyon sa Aplikante) ng benepisyo ay maaaring mapawalang
bisa o hindi)

Revocable Irrevocable

Revocable Irrevocable

Revocable Irrevocable

Revocable Irrevocable

Revocable Irrevocable

Revocable Irrevocable
I hereby apply for Compulsory Insurance Coverage for Agency-Hired Migrant Workers for which I am or may have become eligible, subject to the terms and conditions
of the Group Master Policy. I hereby declare that all statements and answers contained in this application form, together with those statements and declarations stated
in any requested medical examination or questionnaire, which shall form the basis or Pioneer Life Inc./Pioneer Insurance & Surety Corporation to determine eligibility,
are true and complete. I understand that the insurance applied for will not become effective until the payment of the premium and until this application is approved
by Pioneer Life Inc./Pioneer Insurance & Surety Corporation.

Ako ay opisyal na nagpapahayag ng aplikasyon para sa Compulsory Insurance Coverage for Agency-Hired Migrant Workers, kung saan ako ay kwalipikado o maaaring
kwalipikado, batay sa kataga at kondisyon ng Group Master Policy. Ako ay opisyal na nagpapahayag ng pagsang-ayon na ang lahat ng mga nakasaad at sagot sa
aplikasyong ito, kasama ang mga nakasaad at deklarasyon sa mga isinumiteng dokumentong medical at palatanungan, na magiging basehan ng Pioneer Life Inc./
Pioneer Insurance & Surety Corporation upang pagpasiyahan ang aking pagiging kwalipikado sa insurance plan, ay totoo at kumpleto. Ako ay sumasang-ayon na ang
aking insurance plan ay magiging epektibo lamang sa pamamagitan ng pagbayad ng premium at pag-apruba ng Pioneer Life Inc./Pioneer Insurance & Surety Corporation
sa aplikasyon na ito.

“I hereby agree to the recording of all my telephone calls with Pioneer Life Inc., Pioneer Insurance & Surety Corporation and their international assistance provider;
and authorize them to share these telephone recordings, and any other information obtained about me among each other, for any purposes relating to the Compulsory
insurance coverage for agency hired migrant workers, or relating to training and quality assurance.”

In compliance with the Data Privacy Act of 2012, please give us your consent below.
DATA PRIVACY CONSENT
I agree and consent that to the extent required by law, Pioneer Life Inc./Pioneer Insurance & Surety Corporation may collect, use, and process my personal information
contained in my insurance application form for any of the following purposes, in accordance with the Data Privacy Act of 2012 and Pioneer’s Data Privacy Policy:
a. to process my application;
b. to administer my policy/ies;
c. to provide customer service and support;
d. to research and conduct data analytics to improve customer service; and
e. to inform me of latest updates, special offers, and event invites related to my policy/ies.

I am aware and have read Pioneer’s Data Privacy Notice, which contains my rights as a data subject, including the right to access and correction, and the right to object,
may be viewed via www.pioneer.com.ph/about-us/data-privacy-notice.

Yes, I also like to get special offers, event invitations, and updates from Pioneer Life Inc./Pioneer Insurance & Surety Corporation sister companies and partners (list
of member companies and partners is shown on www.pioneer.com.ph/about-us). I understand that this requires sharing of my personal contact information with these
sister companies and partners with the assurance that my personal contact details are handled with the utmost care and confidentiality.
Name and Signature: Date and Place:

Note: The security of your personal information is our priority. We protect this information by maintaining physical, technical and organizational measures
in accordance with the Data Privacy Act of 2012 and other legal requirements, and by following the best practices on data security.
If you have any questions or concerns about your information and/or how we process your personal data, you may contact us through email
at service@pioneer.com.ph or call us at (02) 750-5433 from 8 am to 6 pm, Mondays to Fridays.

TO BE FILLED UP BY THE PAYOR/POLICYHOLDER/RECRUITMENT AGENCY/MANNING AGENCY:

Term of Employment: From / Departure Date: To / End of Employment Contract:
Name of Agency: Agency Contact No.:
Address of Agency: E-mail Address of Agency:
Signature over Printed Name of Authorized Signatory Date and Place:

PIONEER LIFE INC. | PIONEER INSURANCE & SURETY CORPORATION

Pioneer House Makati, 108 Paseo de Roxas, Legazpi Village, Makati City 1229, Philippines
Tel: +63 2 8812 7777 or +63 2 7750 9999 • Fax: +63 2 8817 1461 • www.pioneer.com.ph