CLIENT’S INFORMATION SHEET

A. OWNER /LIFE TO BE INSURED

NAME (LAST, FIRST, MIDDLE): QUIBAL, KIMBERLY KAYE BASTIAN
OTHER LEGAL NAME: N/A

GENDER: FEMALE
BIRTHDATE (DAY/MONTH/YEAR): 29/02/1996

CIVIL STATUS: SINGLE

AGE: 27

CITIZENSHIP/S: FILIPINO

BIRTHPLACE: LA TRINIDAD, BENGUET

TIN: 477-806-423-000
SSS/GSIS NO: 34-5534947-8

EMAIL: kimberlykaye37@gmail.com
HOME PHONE: 09195212659

WORK PHONE: 09666807753

MOBILE PHONE: 09666807753

PERMANENT ADDRESS: 65 SMITH DRIVE, UPPER KM 5, PUROK 8, ASIN ROAD BARANGAY, BAGUIO CITY, BENGUET
PRESENT ADDRESS: 72B MIDLAND MANOR II, ORTIGAS AVENUE, SAN JUAN CITY, METRO MANILA

PRIMARY OCCUPATION: ADMINISTRATIVE HEAD

TOTAL YEARS IN EMPLOYMENT: 3

NATURE OF WORK: OFFICE

ANNUAL INCOME: 300,000.00

EMPLOYER OR NAME OF BUSINESS: JUST ESSENTIALS DISTRIBUTION INCORPORATED

BUSINESS ADDRESS: 138C 14TH AVENUE, SOCORRO, CUBAO, QUEZON CITY

OTHER OCCUPATION: HEAD OF MARKETING / CORPORATE INNOVATORS BAGUIO INCORPORATED

PREVIOUS OCCUPATION AND NAME OF PREVIOUS EMPLOYER (IF PRESENTLY UNEMPLOYED OR RETIRED):
N/A
SOURCES OF FUNDS: PAYROLL

HEIGHT 5’4”
WEIGHT: 65 KGS
B. BENEFICIARY INFORMATION
I. PRIMARY BENEFICIARY:
NAME (LAST, FIRST, MIDDLE) QUIBAL, CARMEN HAZEL BASTIAN
Address: 65 SMITH DRIVE, UPPER KM 5, PUROK 8, ASIN ROAD BARANGAY, BAGUIO CITY, BENGUET
RELATIONSHIP: MOTHER
CITIZENSHIP/S: FILIPINO
Contact Number 09613816995
BIRTHDATE (DAY/ MONTH/ YEAR) 18/05/1973
Birth Place LA TRININDAD, BENGUET
REVOCABLE/ IRREVOCABLE? : REVOCABLE

NAME (LAST, FIRST, MIDDLE) QUIBAL, REDENTOR ABAD

Address: 65 SMITH DRIVE, UPPER KM 5, PUROK 8, ASIN ROAD BARANGAY, BAGUIO CITY, BENGUET
RELATIONSHIP: FATHER
CITIZENSHIP/S: FILIPINO
Contact Number 09077783124
BIRTHDATE (DAY/ MONTH/ YEAR) 13/12/1969
Birth Place BAGUIO CITY, BENGUET
REVOCABLE/ IRREVOCABLE? : REVOCABLE

NAME (LAST, FIRST, MIDDLE) QUIBAL, DENZEL JAYE BASTIAN

Address: 65 SMITH DRIVE, UPPER KM 5, PUROK 8, ASIN ROAD BARANGAY, BAGUIO CITY, BENGUET
RELATIONSHIP: BROTHER
CITIZENSHIP/S: FILIPINO
Contact Number 09664332630
BIRTHDATE (DAY/ MONTH/ YEAR) 10/10/1993
Birth Place LA TRININDAD, BENGUET
REVOCABLE/ IRREVOCABLE? : REVOCABLE

II. CONTINGENT BENEFICIARY

NAME (LAST, FIRST, MIDDLE) QUIBAL, IVAN JONES BASTIAN
RELATIONSHIP: BROTHER
CITIZENSHIP/S: FILIPINO
BIRTHDATE: 25/01/2000

NAME (LAST, FIRST, MIDDLE) QUIBAL, LILEE ZELINE BASTIAN

RELATIONSHIP: SISTER
CITIZENSHIP/S: FILIPINO
BIRTHDATE: 31/10/2006

C. INSURANCE HISTORY :
DO YOU HAVE ANY INSURANCE POLICIES IN-FORCE OR PENDING WITH THE COMPANY AND OTHER INSURANCE
COMPANIES? Y Click or tap here to enter text. N X

INSURANCE COMPANY YEAR TOTAL LIFE INSURANCE COVERAGE TOTAL AMOUNT OF CRITICAL
ISSUED ILLNESS COVERAGE
Click or tap here to Click or Click or tap here to enter text. Click or tap here to enter text.
enter text. tap here
to enter
 text.
Click or tap here to Click or Click or tap here to enter text. Click or tap here to enter text.
enter text. tap here
to enter
text.
Click or tap here to Click or Click or tap here to enter text. Click or tap here to enter text.
enter text. tap here
to enter
text.

D. FAMILY HISTORY

FAMILY AGE HEALTH CONDITION/ AGE AT CAUSE OF DEATH

MEMBER (IF ALIVE) MEDICAL DIAGNOSIS DEATH
FATHER 53 N/A N/A N/A
MOTHER 50 HYPERTENSION N/A N/A
BROTHERS 29 N/A N/A N/A

23 HYPERTENSION
SISTERS 16 N/A N/A N/A

E. PROPOSED INSURED

QUESTION Doctor’s Name & Date Seen Reason for visit or Result of Medical
No. Complete Address (Month & Year) diagnosis
Click or tap Click or tap here to enter Click or tap Click or tap here Click or tap here to
here to text. here to enter to enter text. enter text.
enter text. text.
Click or tap Click or tap here to enter Click or tap Click or tap here Click or tap here to
here to text. here to enter to enter text. enter text.
enter text. text.