UNIFIED GROUP

FRANCHISE FORM
DISTRIBUTION CHANNEL:
Important: Please write in print format.
Corporate Solutions
MCBL
Partnership Distribution
INFORMATION ABOUT THE COMPANY/ACCOUNT: (Please take note to indicate all needed information below)
Registered Business Name:
Address: Tel. No.:
Nature of Business: Years in Operation:
Contact Person: Designation:
Proposal Addressee: Designation
Current Insurance Provider: Policy Effective Date:

 Product line to be offered to the client:

GYRT (Group Protect / Employee Security Program) Loan Secure / Group Credit Life
Exigence – Packaged Group PA Retirement (Affluence Max Gold)
Student Protect / Student Personal Accident (SPA) Salary Savings Insurance Program / Worksite Marketing

EMPLOYEE SECURITY PROGRAM EXIGENCE – GROUP PA LOAN SECURE – GROUP CL

Optional Riders Optional Riders Loan Type __________________________
Total Permanent Disability Min. Loanable amount_________________
Accidental Death, Disablement & C Temporary Total/Partial Disability Max. Loanable amount ________________
C Dismemberment C
V Accidental Medical Reimbursement Ave. Loan release per Month____________
Accidental Medical Reimbursement
C
V Hospital Indemnity
C Ave. No. of Borrowers per Month
C Total Permanent Disability VEMPLOYEE SECURITY PROGRAM
Optional Riders

_____________
Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

GROUP PROTECT
Optional Riders
Accidental Medical Reimbursement
Hospital Income
Cancer Critical Illness

C RETIREMENT:
V AMG
Total No. of Borrowers ________________
EMPLOYEE SECURITY PROGRAM
Optional Riders

GROUP PROTECT
Optional Riders
Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

Accidental Medical Reimbursement

Hospital Income
Cancer Critical Illness

Total Disability Income

C Hospital Income Retirement Age:
Optional Riders

60 65
EMPLOYEE SECURITY PROGRAM

Ave. Age of Borrowers ________________

Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

GROUP PROTECT
Optional Riders
Accidental Medical Reimbursement
Hospital Income
Cancer Critical Illness

C Salary Increase: 3% 5% 7% Loan Budget for the Year ______________

EMPLOYEE SECURITY PROGRAM
Optional Riders

GROUP PROTECT
Optional Riders
Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

Accidental Medical Reimbursement

Hospital Income
Cancer Critical Illness

CI 60
C Name of Keyman: __________________ Borrower’s Profile (choose what’s applicable)
Cancer Critical Illness
C
V Terminal Illness DOB of Keyman: __________________ Employees ___%
C Business Owners ___%
Burial Assistance High-risk Occupations
C
EMPLOYEE SECURITY PROGRAM
Optional Riders
Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

GROUP PROTECT
Optional Riders
Accidental Medical Reimbursement
Hospital Income
Cancer Critical Illness

Salary Savings Insurance Program (SSIP)

Name of Payroll Officer___________________ (Military, Police, Guard, Linemen, etc) ___%
GROUP PROTECT Office Address__________________________ Retirees/Pensioners ___%
Optional Riders Others
Email Address___________________________
Accidental Medical Reimbursement
C Hospital Income Contact Number _________________________ Specify_____________ ___%
C
V Cancer Critical Illness
Payroll Cut-Off Date _____________________
C
V
Service Fee % __________________________
V
EMPLOYEE SECURITY PROGRAM
Optional Riders
Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

GROUP PROTECT
Optional Riders
Accidental Medical Reimbursement
Hospital Income
Cancer Critical Illness

Claims Experience (for accounts with existing provider only)

EMPLOYEE SECURITY PROGRAM
Optional Riders
Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

GROUP PROTECT
Optional Riders
Accidental Medical Reimbursement
Hospital Income
Cancer Critical Illness

EMPLOYEE SECURITY PROGRAM

Optional Riders

GROUP PROTECT
Optional Riders
Accidental Death & Dismemberment
Accidental Death, Disablement &
Dismemberment
Accidental Medical Reimbursement
Total & Permanent Disability
Total Disability Income
Hospital Income
Critical Illness
Cancer Critical Illness
Terminal Illness
Burial Assistance

Accidental Medical Reimbursement

Hospital Income
Cancer Critical Illness

AVERAGE AMOUNT OF CLAIMS (last 3 years) ________________________

TOTAL NUMBER OF CLAIMS (last 3 years) ________________________
REASONS FOR CLAIMS (death, accident, etc.) ________________________

IMPORTANT: CONFORME
Distribution Channel (Corporate Solutions / MCBL / Partnership Distribution) Authorized Signatory of the Company
Your signature below signifies that you have provided the accurate information Your signature below signifies that you are exclusively authorizing the named
about the company for this franchise application. distribution channel of Manulife to request/transact a proposal in your behalf.
REQUESTOR’S NAME
NAME & SIGNATURE:
& SIGNATURE:
IA CODE (FOR AGENCY)
DESIGNATION:
& EMAIL ADDRESS:
IMMEDIATE MANAGER: DATE:

TO BE FILLED OUT BY CORPORATE SOLUTIONS / PARTNERSHIP DISTRIBUTION OFFICERS ONLY

Product Approved: Date of Approval: Expiration of Franchise:

REV. OCT.2.2019