Travel Insurance Application Form

Instruction: Please fill up in BLOCK LETTERS and return the completed form to us.

NAME
R E Y E S J A M I K A A N T O N E T T E P A N T I N O P L E
Last Name First Name Middle Name
PRESENT ADDRESS
A B A N I L A G U A D A
Number Street Subdivision/Village Barangay
O Z A M I S C I T Y M I S A M I S O C C I D E N T A L 7 2 0 0
Municipality/City Province Zip Code
OWNERS/LESSORS OF THE HOUSE OCCUPIED:
PERMANENT ADDRESS
P U R O K 1 P O B L A C I O N
Number Street Subdivision/Village Barangay
M A H A Y A G Z A M B O A N G A D E L S U R 7 0 2 6

Municipality/City Province Zip Code

OWNERS/LESSORS OF THE HOUSE OCCUPIED:

PHONE NUMBER/S Mobile Number 0 9 5 1 5 3 3 0 8 5 6 Home/Office Phone Number
3 (If provincial, include Area Code)
E-MAIL ADDRESS: jamika.reyes.jr@gmail.com
Would you like to receive your policy and notifications in e-format thru email? Y
N
CIVIL STATUS Single Married Separated Widowed GENDER: Male Female

NUMBER OF CHILDREN DEPENDING FOR SUPPORT: CITIZENSHIP F i l i p i n o

DATE OF BIRTH 0 9 / 16/ 2001 PLACE OF BIRTH: Pob. Mahayag ZDS
mm dd yyyy

SOURCE OF FUND(S): Salary Business Donation Inheritance Others

TYPE OF EMPLOYMENT:
(Main Source of Income)
Employed Tax Identification Number (TIN)
Private SSS Number:
Government & Government-related GSIS Number:
OFW
Position:
Professional
Business (Self-employed)
Others
ISIC CODE * :
NAME OF EMPLOYER (if any)
ADDRESS (if any)
SALARY / INCOME SCALE: (Please Check)

not over Php 10,000 over Php 140,000 but not over Php 250,000
over Php 10,000 but not over Php 30,000 over Php 250,000 but not over Php 500,000
over Php 30,000 but not over Php 70,000 over Php 500,000
over Php 70,000 but not over Php 140,000

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INDUSTRY:
Agriculture, Forestry & Fishing Real Estate Activities
Mining & Quarrying Professional, Scientific and Technical Activities
Manufacturing Administrative & Support Service Activities
Electricity, Gas, Steam & Air Conditioning Supply Public Administration & Defense; Compulsory Social Security
Water Supply; Sewerage, Waste Management & Remediation Activities Education
Construction Human Health and Social Work Activities
Wholesale & Retail Trade; Repair of motor vehicles & motorcycles Arts, Entertainment & Recreation
Transportation & Storage Other Service Activities
Accommodation & Food Service Activities Activities of Households as employers; undifferentiated goods-
Information and Communication and-services producing activities of households for own use
Financial and Insurance Activities Activities of Extraterritorial Organizations & Bodies

Please answer all of the following questions with YES or No

1. Have you been a patient in a hospital, clinic or sanitarium in the past 5 years? Yes No
If YES, please give details. ULCER & UTI INFECTION

2. Have you ever availed of any medical or surgical treatment? Yes No

If YES, please give details. ULCER & UTI INFECTION

3. Have you ever been advised to have any diagnostic test, hospitalization, or surgery which was not Yes No
done or completed? If YES, please give details.

4. Have you applied for or received payment for sickness/injury? Yes No

If YES, please give details.

5. Have you been rejected for insurance/health care plans or offered insurance at higher premiums? Yes No
If YES, please give details.

6. Do you take alcohol, cigarettes, tobacco or any habit-forming drug? Yes No

If YES, please give details.

7. Have you experienced any abrupt change in body weight recently? Yes No
If YES, please give details.

8. Are you presently taking any medication? Yes No

If YES, please give details. Cough
9. (for WOMEN only)
Date of last delivery:

Are you pregnant? If YES, how many months? Yes No

Abortion, miscarriage, abnormal labor/pregnancy? Yes No

If YES, please give details.
Name and address of personal physician:

Date of last consultation:

Treatment given/medication prescribled:

Do you have a personal history of any of the ff: (if YES, please check)
10.
Arthritis/Rheumatism Hemmoroids/Anal fistulae
Asthma/Tuberculosis/Pulmonary hypertension High Cholesterol/Dyslipidemia
Blood dyscrasia /Leukemia/Anemia High blood pressure/Hypertension
Bone disease/Osteoporosis Injury from accident or assault
Cancer/Malignant tumor Kidney or urological disease
Cataract/Glaucoma Liver disease/Hepatitis/Cirrhosis
Central nervous system disease Meningitis/Encephalitis
Cerebral palsy Myoma/Ovarian Cyst/Breast mass/Endometriosis

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 Congenital heart disease/MVP Organ transplant
Congenital illness/Down’s syndrome/Autism Physical deformity or disability/Spinal stenosis
COPD/Emphysema/Chronic Bronchitis Prostate Problem
Craniotomy/VP shunt Psychiatric disorder/Psychosis
Cyst/Tumor of internal organ Rheumatic fever/Rheumatic heart disease
Diabetes Mellitus Sexually transmitted disease/AIDS
Epilepsy Stroke/Cerebrovascular accident
Eye, nose or throat tumor/Sinus requiring surgery Ulcer/Colitis/Diverticulosis
Gall bladder or biliary stones Urinary tract stone/Chronic renal failure
Goiter/Hyperthyroidism Other/s:
Heart attack/Heart disease

11. Do you engage in any strenuous, physical or hazardous activities, sports or hobby? Yes No
If YES, please give details. football

DATA PRIVACY I acknowledge that Malayan Insurance Company, Inc. (Malayan) may collect, use, process and share my personal information to its employees, duly
authorized representatives, other insurers, reinsurers, adjusters, investigators, and other third party providers for purposes such as underwriting, administration,
claims adjudication and management, investment, data analytics, statistical analysis, risk analysis/ assessment/management, financial and tax
monitoring/review/reporting, protection against fraud, errors, or misrepresentations, profiling, research, due diligence, company evaluation, studies/customer
satisfaction surveys, and compliance with legal, regulatory or contractual requirements. Further, I agree that Malayan may notify and offer me any of its products and
services that may be useful to me. In furtherance of these purposes, my personal information, unless prohibited, may be processed outside the Philippines and be
subject to different data protection standards.
AUTHORITY TO VERIFY INFORMATION I also authorize Malayan to verify and investigate the information given by me, including submitted documents from whatever
source it may consider appropriate.
RIGHTS OF THE DATA SUBJECT I acknowledge that I have the right to access the given information and I undertake to correct, rectify or supplement the same should
any information be found to be inaccurate or incomplete. I shall notify Malayan in writing of any changes in the information given above.
UNDERTAKING I hereby warrant that all personal information given by me are true, correct, updated to the best of my knowledge, and freely and voluntarily given to
Malayan. I agree and consent that the above information are being collected, used, processed and recorded for purposes of securing insurance protection or any other
business transaction(s) with Malayan and for other purpose as indicated herein.
If purchasing, transacting and/or acting in behalf of other person(s), I hereby warrant that I have been duly authorized to perform such acts and permitted to give their
information to Malayan. I hereby bind myself to advise all other persons in whose behalf I have acted, transacted with and/or purchased any product or services from
Malayan of all the terms and conditions herein. I will hold Malayan, directors, officers, employees, agents, successors and assigns free and harmless from any liability
that may arise as a result of the authorization given above.
By signing this form, I hereby certify that I have read and understood the foregoing and this consent remains valid and binding unless I submit a written notice to
Malayan revoking or altering the same.
AUTHORITY TO DISCLOSE By ticking the box, I hereby authorize Malayan to grant the members of the Yuchengco Group of Companies (YGC), their and
Malayan’s affiliates, subsidiaries, contractors, partners, agents and representatives, intermediaries, industry associations, and other third parties access to my
personal information, including this form, for purposes of marketing, sales or promotional information campaigns, and provision of any products, services, or offers
through mail/email/SMS/telephone, or any type of electronic facility.

IN WITNESS HEREOF, I have signed this Application on NOV. 13, 2023 in OZAMIS CITY .

Signature: JAMIKA ANTONETTE P. REYES Signature:

(Client’s signature over Printed Name/ Date Signed) (Broker, Agent and other Authorized Representative of Client/ Date Signed)

This portion to be filled up by Malayan Insurance:

Verified by: Date Received:

(Name & Signature of Malayan Insurance frontliner)

Note: Please accomplish and submit form together with a copy of your valid ID (e.g. Government issued ID/s – SSS/GSIS/Philhealth, Driver’s License,
Passport, etc.) Application Form may be sent via e-mail: csc@malayan.com ; fax @ 243-1033 or via Postal Mail: 500 ETY Building Quintin Paredes
St., Binondo, Manila 1006

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 Travel Information
TYPE OF TRAVEL: PURPOSE: TYPE OF PLAN:

Local Business Peso Policy

Asian Leisure Dollar Policy

Worldwide Others

No. of Days: 3 DAYS Inclusive Dates: from DECEMBER 6, 2023 to DECEMBER 8, 2023

Destination / Itinerary: CEBU CITY

Commencement of Travel / Departure: DECEMBER 6, 2023

Conclusion / End of Travel / Arrival: DECEMBER 8, 2023

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