aumeeman a | Charter Ping An ‘Accomplish the details and put “N/A” if not applicable. Print legibly using BLACK INK. ‘Any erasure should be countersigned by the Proposed Owner. This form must be filled Policy Number O Onw © Renewat Application for General Insurance — *#<#err: out by the Proposed Owner or by a person acting under the Owner's direction and authority Important Notes: 1 An Insurance is a contract of utmost good faith and the Proposed Owner is required to disclose ALL material facts to the insurer. ll answers to the questions stipulated Inthis ‘questionnaire are the basis of and are an inseparable part of the insurance policy. In ‘case of doubt as to whether a fact is material or not, the fact should be disclosed. 2. Please do not sign on a blank form. 3. Please shade the circle to indicate your ehoice(s). FOR OFFICIAL USE ONLY Date Received Time Receivee: Receiving, Dept /omtie: VEN NAME (nama Aurhozed Seaton) CLETTTTIT TTT Tritt titi t rir yy) [TTT TT I REGISTERED NAME o2vporaton Parnes) FORINDIVIDUALS AUTHORIZED SIGNATORY CLET TTT TTT rt tr rt r irr) pusce oni saniowairy ‘ev wo. cass ee) Orns Ores ‘ae wri ervam20) | wr Nature of Busness/Work soe nate source fun Hemp nonce rane fee ante Pamir tna Pn fain esac rn sare arn am pen | mncone (CONTACT NUMBERS vs atte) I 0 CO-Appllestion for Genaral Insurance Application Number: secemmcrrmann, | a [meee ‘unonsury a Orente Natur of Basinoar/ Wer Puasa ceo Tan pace ra fang sty (Peseta Payton Sang Sece Sung iy Pe ZC) ‘ecooe CONTACT NUMBERS ow stp owe nen Mooi NUMBER Manso) ns ABonEae y) Een aurncussaan ‘A. WWe declare that all foregoing statements are true and /we have not withheld any material infomation regarding this application. 6. Any of my/our personal information collected or held by Chater Ping An Insurance Corporation (CPAC) (whether contained inthe appication/s or otherwise) inay tad connecting whatever purpose wi uch te personal formson aoe may os waee sored, dace anerred {rieter wihin gr ove te Prispoines) fo such persons antes as CPAC ray consider necssnay fncludig but not miedo ary offs aiaated Pareto folalad compare ary nikal ogaaaina appa etna avant wh ‘Process and deal with my sopleaton/ oly and protcy all orice (lated to ry appteaton poly i Promote thr jrou/srtoss by CEA and std of eltbd compare hes, ni pass my maton fx prodet devtpment Communicate wih! me for ay purpose and/or to comply wth the las of any applicable jursdiction. ©. yWe understand thet CPNC shal uae my: parsnal infomation o eval and asese my/ Or appization and nea for naranee a wall a0 serico ‘ny of my/our poles and neeas jnulhg tis evaluation of ay futuro lam, PWo abo autre CPAKC to discos to aiatodortitjes) oo persons br ontiiespronding services on CANC's baal consistent wih the purpose for wich the formation was Obie . We understand that company notices related to my/our policy wil be sent to me/us though email or SMS in the address/aumber I/we provided abv, ‘otherwise, sent fo me/ ls to my/our preferred maiing adress We understand that my poy coverage wil aks fect upon succosfl payment of my/our nal premium, ad deber ofthe pokey unas agreed F. Wo declare that /we have informed CPMC of ally citzershinsresidancis and tax residences, and provided CPAIC with my/our IVa Sgro to prompt update CPR of ay chong to sid ioraion 6./We authorize OPA to disclose my/our personal intrmation to any government or tax authory (within or ouside the Philipines) or the purposes of ‘aing GPATEs compliance mith apples lawe and regutons, H.W understand that we have the right o assess our personal information at anytime correc of rectily any information colectas or held by CPAIC which srelnacctata, lie, or ncerplats ject case of dy urainonsod Colston ease Se OER wonton witch sonia, dated ani aa ad Such othor igs os may be avalabla nda the Data Privacy Act | We ages that CPAIC shall have the right to (a) roquie the owners, claimani{s) and/or payoos) ofthe Pi to provide CPAIC wth thet above-mentioned pets ntomsion nds un sun dosnt SOE may seasonaiy reqs 6] ans daclose Sls persona srometon toy gvernmane Era authory (nee wit or ut fe Phas) rth prpeaes of GAR cmphance with appetite ws agar we ao do a ahi shoe urn ata ae tet Cc may pee mo personal amaton Such Bnerimart nat ato} to aM ification numbers. **PLEASE DO NOT SIGN ON A BLANK FORM Date of signing: Place of Signing: Signature of Client / Authorized Signatory over printed name Signature of Client / Authorized Signatory over printed name-Appllestion for Genaral Insurance Application Number: ‘SURNAME, FIRST NAME, MIDDLE NAME [RELATIONSHIP] DATE OF BIRTH (YYYY/MIM/OD) Porconenos ‘SURNAME, FIRST NAME, MIDDLE NAME [RELATIONSHIP] DATE OF BIRTH (YYYY/MM70D)