Individual Enrollment Form for Group Insurance

Personal Information
Last Name First Name Middle Name
FOR PIONEER LIFE USE ONLY
Sales Mario Manuel Jr. Feliciano
Birthdate (mm/dd/yyyy) Birthplace Age Sex Height Weight Group Policy No.
03/07/1992 Manila 30 Male 5'6 140 lbs Certificate No.

Residence Address Civil Status Nationality Effective Date

35B Caballero St. Greenland Executive Cainta Rizal Married Filipino

Amount of Insurance:
Contact Number(s) SSS/GSIS Number Tax Identification Number (TIN)
0915 887 2516 3431278848 313 067 124 000 Basic Life

Name of Employer/Association/Creditor Occupation/Position Accident

Datacom IT Systems (Phil) Inc. Sr. QA Automation Engineer TPD

Bereavement
Date of Employment/Membership/Loan Term of Loan (if Group Credit Life) Amount of Loan (if Group Credit Life)
Approval (mm/dd/yyyy) Others
September 19,2022 (pls. specify)
Beneficiary Designation
Full Name (Last, First, Middle) of Beneficiary(ies) Birthdate (mm/dd/yyyy) Age Relationship to Insured
Norijean RIzza Alcantara Sales November 9, 1993 28 Wife
Marilyn Feliciano Sales February 14, 1960 62 Mother

I hereby certify that the personal data contained herein are true and correct.
Mario Manuel Sales Jr. September 20, 2022
Signature over printed name of applicant Date (mm/dd/yyyy)
PIONEER LIFE INC.
Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph