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  • S36BW 823081110140

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    NIKITA UCHIYAMA
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    S36BW-823081110140

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    6 views2 pages

    S36BW 823081110140

    Uploaded by

    NIKITA UCHIYAMA

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    LIFE & GENERAL Telephone +632.8772 9200 Fax +63287729291 FOR MIGRANT WORKER APPLICATION FORM 1th 6 15 lor, Sage House, 110A Rufino Stet, PARAMOUNT | (egzpiVilgs lat ly 1259, Pilppines COMPULSORY INSURANCE COVERAGE INSURANCE aniparsmountcomph Nature of Employment: (1 Agency-Hired 0 Direct-Hired Ef Balik Manggagawa / Re-hired FWPEOFRACAGE TERTOFEVRLOWENT (BTID [ohn PORE S| TENT AGENCY D Seo bone ' SE PRIME Lan Base From ia 36 RECRUITMENT SPECIALIST int” _| PERSONAL INFORMATION / IMPORMASYON NAUUKOL SA APLIKANTE ‘LAST NAME (Apelyido) |FIRST NAME (Pangalan) [MIDOLE NAME (Gitnang Ngalan) CARATUAN | Je ANN PEToN/0 GENDER Kosar) OIC STATUS Kalagayeng Sei) DATE OF BIRTH (Pts ng Kapanganatan) [PLAGE OF BIRTH (garg Kepananatn) Male (Lalak’) Kisingle O Widower _ [raremaleGabce) cred CLegaly Separate | Jay, et, ABZ Lurugn city |STREET ADDRESS (Numero af Kalye) [CITY TMUNICIPALITY (LungsodiMtunisipya) 2217 STH <7 GulacorA UP Burn CF, IPROVINGE alawigan INOBILETLANOUNE IAL : ACA? DEL NoRTE 099 G02 09/8 joonmenbatuangze groi)Con EMPLOYMENT INFORMATION / IMPORMASYON UKOL SA TRABAHO AT KUMPANYANG PAGTATRABAHUHAN [OCCUPATION Crabaho) STUNTED NCATE SAAR pestaryFOREGNEMPLOVER Pangan poser) PonTRY FARMER |" fon HiRANo* Thndcn [STREET ADDRESS (Numero at Kalye) . [CITY 7 TOWN (LungsodiBayan) — 8-72 WROTE MinAMi MACH’, Minami Jeu Fukvor, KEY PROVINCE STATE (lagen) COUNTRY ara FukuokA- Ar | NPan NAME OF BENEFICIARY/IES / PANGUNAHING KAANAK NA MAKAKATANGGAP NG BENEPISYO LastName Mie nial FirstName Reakreis Peposedinsaed | Teephone Number (oes) | (einer Naaen (Pangan) (Relasjn sa Appikat) {Teepon) » PETANIO Garcia | Maria Leda MoTHER 0973 026097, CARATUAY) Betonio | Raizg CHILD C%DOL69995. CAR ATUAN | Morgatie2, Roldor PalBAnd TUS 20 052 \ hereby apply for participation inthe Compulsory Insurance Coverage for Migrant Worker plan for which | am or may have become eligible for, subject to the terms ‘and conditions ofthe Master Policy. hereby agree that my insurance shall Become effective Upon approval of the Company provided that | have metal eigibliy conditions and am in good health on such date and when the fll premium corresponding to my insurance coverage has been paid | hereby declare and agree that all he foregoing slatements, delaratons, and names inthis application form together with those stated in any requested medical examination, questionnaire, or amendment, are complete and true and correc recorded and shall form the bass fr Paramount Life & Ganeral insurance Corporation, to determine eight for the Compulsory Insurance Coverage for Migrant Worker and which, wit the Master Poicy and its attachments, wll constitute the entire contract. During the efectity ofthe contracpalcy, We agree or consent to the following (1) Ifby reason of mylour faut, the company failed fo comply with the relevant Customer Due Diligence (CDD) Measures, as required under the Ant-Money Laundering Act and its related rules and reguatons, the Company may exercise the folowing (a) Measure oes the sence aval oro ary ite tnsactons on te contacpoity ut tl proper COD measures have bee suzcessuly conducted; an (b) Inthe event the COD measure is unsuccessful, the company may terminate business relafonship. But the cen customer is entited to receive the unused Portions of premium or withdrawal value if any, whichever is applicable. (2) Be bound by obligations set forth in relevant United Nations Securty Council Resolutions, relating to the prevention and suspension of profferation of francing ‘of weapons of mass destruction, wherein it may include the freezing and unfeezing actons as wel as prohiaitons from conducting ransactons with designated persons and entities. sinecat CHARTREWE PRIME entre AUCUST cy I) year 202% Jo Ain CABATUAD (Nilagdaan sa) ike) (araw ng) (ta0ng) ynature of Insured {Lagde ng Aplixante) tay pai er Aen re) = Dae ar Saray] ‘Ako ay opisyal na nagpapahayag ng apikasyon para sa partisipasyon ng Compulsory Insurance Coverage for Migrant Worker, ung saan ako man ay, 0 maaating maging kwaipikado, batay sa mga ketaga at kondisyon ng Master Policy, Ako ay sumasang-ayon na ang aking insurance plan ay magiging epekibo lamang 3 ‘pamamagitan ng pap-apruba ng Kumpanya balay sa aking paglugon sa mga kwallpkasyon at batay sa aking pagkakaroon ng maayos na kalusugan sa arav’ 'g pag-bayad ng kabwang premium na isinasaad ng sakiaw ng insurance. Ako ay opiyal na nagpapahayeg ng pag sang-ayen na ang lahat ng mga nakasaad, PPHLCABATUANS

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