INFORMATION SHEET

Name:_____________________________________________________________________DATE TODAY:______________________
Last Name First Name Middle Name Alias
Birthdate:_________________________ Age:___________ SMOKER/NON-SMOKER _______________ No. of sticks per day: ______
Birth Place:____________________________________________________ Citizenship/s ______________ Gender:______________
Permanent Address:___________________________________________________________________________________________
Residence Address:____________________________________________________________________________________________
Mailing Address:______________________________________________________________________________________________
Civil Status: _____________ Occupation: ___________________________ Duties and Responsibilities:________________________
Name of Employer:____________________________________ No. of years in employment/ business:________________________
Nature of Business:_____________________________ Business Address:________________________________________________
If Unemployed, Previous Occupation and Employment: _________________________________________________________
SSS/GSIS:___________________________________________ TIN No.:_________________________________________________
Contact #: HOME: _______________________ OFFICE:______________________CELLPHONE NO:______________________
E-mail Address: _______________________________________________ Estimated Annual Income:__________________________
Religion:_____________________________________ Height:___________________ Weight:____________________
Any Government Position/ Family Member: _______________________________________________________________________
Total insurance coverage : Sunlife ___________________________________________ Date Issued: _________________________
Other company/Name of company ________________________________ Date Issued: ____________________________
If Married, kindly fill up information below:
Spouse: ____________________________________________________________________________________________________
Last Name First Name Middle Name Birthdate
Amount of insurance of husband (If married)_________________________________ YEAR ENFORCED:________________
How do you know about the life to be insured or applicant? Through____________For :Lifetime/__/Years /___/Just met/__/
Family History:
AGE STATE OF HEALTH AGE DIAGNOSED AGE OF DEATH CAUSE OF DEATH
Father
Mother
Brother
Sister
Beneficiary: ***PRIMARY;***
(Last Name, First Name, B-DATE RELATIONSHIP CITIZENSHIP IRR/ BIRTH PLACE PERMANENT MOBILE NO.
Middle Name) REV ADDRESS
1.

2.

3.

****CONTINGENT;****
1.

2.

*For Woman Only:

1. Are you pregnant? _________Number of months? ____________
2.Any complications of pregnancy? Y/N State complicaton:__________________________
3.Do you have /had any gyecological problem? Y/N Pls provide details on GYNE problem:___________________________

Do you have within the past five (5) years had the ffg: YES NO
1. Consulted any Doctor?
2. Submitted to ECG, X-Ray, Blood Test and other Test?
3. Attended or have been admitted to any Hospital?

_____________________________________
SIGNATURE