Part 1 – Plan Data

Plan Type: St. George

Mode of Payment: Monthly

Part 2 - Plan Holders Personal Information

Last Name: Pristo / First Name: Jonard Arjay / Middle Name: Laxamana

Residential Address: Lot#: 62 / Street: N/A/ Barangay: Dela Paz Sur / City: San Fernando/ Province: Pampanga/ Zip Code:
2000

Nationality: Filipino

Contact number: 09504009476/ Email Address: jonardpristo@gmail.com

Date of Birth: April 21, 1997/ 04/21/1997

Place of Birth: V.L. Makabali Memorial Hospital Inc, San Fernando City, Pampanga, 2000

Sex: Male/ Civil Status: Single/ Height: 5’8 feet (176 cm) / Weight: 76 kg.

Occupation: Self Employed

TIN: 714-042-830-000

Beneficiaries

1. Name: Debbie L. Pristo / Age: 55 / Address: #62 Dela Paz Sur , San Fernando City, Pampanga 2000/ Relationship:
Mother
2. Name: Mickaella Arjay L. Pristo / Age: 25/ Address: #62 Dela Paz Sur , San Fernando City, Pampanga 2000/
Relationship: Sister
3. Name: Mariella Arjay L.Pristo / Age: 17/ Address: #62 Dela Paz Sur , San Fernando City, Pampanga 2000/
Relationship: Sister

Contingent:

1. Name: Mickaella Arjay L. Pristo / Age: 25/ Address: #62 Dela Paz Sur , San Fernando City, Pampanga 2000/
Relationship: Sister
2. Name: Mariella Arjay L.Pristo / Age: 17/ Address: #62 Dela Paz Sur , San Fernando City, Pampanga 2000/
Relationship: Sister

Signature: