INFORMATION SHEET

Policy Owner/ Proposed Life Insured

Name: Oeneri Don Esquilona Ocampo Gender: Male Height & Weight: 5’4” & 65kgs
Maiden Name: Nationality: Filipino
Date of Birth: March 19, 1994
Place of Birth: Marikina City
Civil Status: Married
Salutation:
Mobile No.: +63 9216000178 Telephone No.: (02)863-44585
Email Address: oeneriocampo@gmail.com
TIN/SSS/GSIS: 461-067-278-000
Gross Annual Income: Php750,000
Net Worth: Source of funds: Salary □Business □Others ______________________
Occupation: Bike Consultant Nature of work or business: Bicycle Industry
Employer: Bikes Online Nature of business of the employer: Bicycle Industry
Present Address: 5B Lance St. Brgy. Mambugan Antipolo City, Rizal
Permanent Address: 33 Sunny Square Drive Malanday Marikina City
Business Address:
Preferred Mailing Address: □Present Address Permanent Address □Business Address
Any existing insurance policy? N/a
Any pending or declined application for insurance? N/a
PERSONAL HISTORY: (Medical- treatment, confinement, operations; Lifestyle – hobbies, avocation)
Hobbies- badminton, mountain biking, outdoor activities

FAMILY HISTORY: (age, health condition; if deceased†, age at & cause of death)
Father: 65, good
Mother: 65, good
Spouse: 29, good
Siblings: 40, good ; 32,good
Children: 6, good

PRIMARY BENEFICIARIES:
Name Relationship to % of R – Revocable Gender Date of Birth Place of Birth Nationality
insured share Irr - Irrevocable
Charlamagne Jam Del Wife 70 R F May 21, 1991 San Mateo, Filipino
Rosario - Ocampo Rizal

Present Address of Beneficiary/ies: 5B Lance St. Brgy. Mambugan Antipolo City, Rizal

SECONDARY BENEFICIARIES:
Name Relationship to % of R – Revocable Gender Date of Birth Place of Birth Nationality
insured share Irr - Irrevocable
Gabe Carlisle C. Palparan Stepdaughter 30 R F January 24, Marikina City Filipino
2015

Present Address of Beneficiary/ies: 5B Lance St. Brgy. Mambugan Antipolo City, Rizal

Valid Govt ID: □SSS □TIN □Passport License □Others ______________________

PAYMENT METHOD:
ADA: BDO □BPI □Metrobank Acct Name: Oeneri Don E. Ocampo Acct #: 010330279688 Branch: SM San Mateo Rizal
Credit Card: □Mastercard □Visa
PDC’s: ________