Republic of the Philippines

PROVINCE OF BOHOL
City of Tagbilaran

OFFICE OF THE GOVERNOR

APPLICATION FOR GOVERNOR’S AID LIFE INSURANCE

All questions must be answered fully

COVERAGE LIMIT OF LIABILITY

Loss of Life __________________Pesos (Php___________)

I HEREBY APPLY for the Governor’s Aid Insurance and declare that the following statements are
true and correct. I agree that this application shall be made as basis in the issuance of ID and benefits by
the Provincial Government of Bohol.

Name (Print Full Name) ______________________________________________________________

Surname First Name Middle Name

Barangay: ADLAWAN Sex: .

Municipality: VALENCIA Civil Status: _________________

Date of Birth:_________________ Place of Birth: _______________

Please check Occupation:

Punong Barangay Barangay Day Care Worker CAFGU
Barangay Kagawad Barangay Health Worker Volunteer Fish Warden
Barangay Treasurer Barangay Livestock Aide LupongTagapamaya
Barangay Secretary Barangay Nutrition Scholar SK Chairman
Barangay Tanod Civilian Volunteers (CVOs)

Designated Beneficiary / ies

NAME Relationship Address

Signed this _________ day of _______________, 2024.

__________________________
Signature of Applicant

Noted:
MAXILINDO T. MAGAN
Punong Barangay

Endorsed by:
JOSE RUBEN H. RACHO
MLGOO

APPROVED:

HON. ERICO ARISTOTLE AUMENTADO

Governor

Endorser:
Punong Barangay Barangay Health Worker Volunteer Fish Warden Mayor
Barangay Kagawad Barangay Nutrition Scholar MHO Civilian Volunteers (CVOs)
Barangay Treasurer
Barangay Secretary MLGOO
Barangay Tanod
LupongTagapamayapa Barangay Day Care Worker – MSWDO CAFGUS – 302nd Brigade
Sk Chairman Barangay Livestock Aide - MAO
 Republic of the Philippines
PROVINCE OF BOHOL
City of Tagbilaran

OFFICE OF THE GOVERNOR

APPLICATION FOR GOVERNOR’S AID LIFE INSURANCE

All questions must be answered fully

COVERAGE LIMIT OF LIABILITY

Loss of Life __________________Pesos (Php___________)

I HEREBY APPLY for the Governor’s Aid Insurance and declare that the following statements are
true and correct. I agree that this application shall be made as basis in the issuance of ID and benefits by
the Provincial Government of Bohol.

Name (Print Full Name) ______________________________________________________________

Surname First Name Middle Name

Barangay: ADLAWAN Sex: .

Municipality: VALENCIA Civil Status: _________________

Date of Birth:_________________ Place of Birth: _______________

Please check Occupation:

Punong Barangay Barangay Day Care Worker CAFGU
Barangay Kagawad Barangay Health Worker Volunteer Fish Warden
Barangay Treasurer Barangay Livestock Aide LupongTagapamaya
Barangay Secretary Barangay Nutrition Scholar SK Chairman
Barangay Tanod Civilian Volunteers (CVOs)

Designated Beneficiary / ies

NAME Relationship Address

Signed this _________ day of _______________, 2024.

__________________________
Signature of Applicant

Noted:
MAXILINDO T. MAGAN
Punong Barangay

Endorsed by:
DR. ROCELYN S. BAJA, MD
MHO

APPROVED:

HON. ERICO ARISTOTLE AUMENTADO

Governor

Endorser:
Punong Barangay Barangay Health Worker Volunteer Fish Warden Mayor
Barangay Kagawad Barangay Nutrition Scholar MHO Civilian Volunteers (CVOs)
Barangay Treasurer
Barangay Secretary MLGOO
Barangay Tanod
LupongTagapamayapa Barangay Day Care Worker – MSWDO CAFGUS – 302nd Brigade
Sk Chairman Barangay Livestock Aide - MAO
 Republic of the Philippines
PROVINCE OF BOHOL
City of Tagbilaran

OFFICE OF THE GOVERNOR

APPLICATION FOR GOVERNOR’S AID LIFE INSURANCE

All questions must be answered fully

COVERAGE LIMIT OF LIABILITY

Loss of Life __________________Pesos (Php___________)

I HEREBY APPLY for the Governor’s Aid Insurance and declare that the following statements are
true and correct. I agree that this application shall be made as basis in the issuance of ID and benefits by
the Provincial Government of Bohol.

Name (Print Full Name) ______________________________________________________________

Surname First Name Middle Name

Barangay: ADLAWAN Sex: .

Municipality: VALENCIA Civil Status: _________________

Date of Birth:_________________ Place of Birth: _______________

Please check Occupation:

Punong Barangay Barangay Day Care Worker CAFGU
Barangay Kagawad Barangay Health Worker Volunteer Fish Warden
Barangay Treasurer Barangay Livestock Aide LupongTagapamaya
Barangay Secretary Barangay Nutrition Scholar SK Chairman
Barangay Tanod Civilian Volunteers (CVOs)

Designated Beneficiary / ies

NAME Relationship Address

Signed this _________ day of _______________, 2024.

__________________________
Signature of Applicant

Noted:
MAXILINDO T. MAGAN
Punong Barangay

Endorsed by:
MARY GRACE B. LIM, RSW
MSWDO

APPROVED:

HON. ERICO ARISTOTLE AUMENTADO

Governor

Endorser:
Punong Barangay Barangay Health Worker Volunteer Fish Warden Mayor
Barangay Kagawad Barangay Nutrition Scholar MHO Civilian Volunteers (CVOs)
Barangay Treasurer
Barangay Secretary MLGOO
Barangay Tanod
LupongTagapamayapa Barangay Day Care Worker – MSWDO CAFGUS – 302nd Brigade
Sk Chairman Barangay Livestock Aide - MAO
 Republic of the Philippines
PROVINCE OF BOHOL
City of Tagbilaran

OFFICE OF THE GOVERNOR

APPLICATION FOR GOVERNOR’S AID LIFE INSURANCE

All questions must be answered fully

COVERAGE LIMIT OF LIABILITY

Loss of Life __________________Pesos (Php___________)

I HEREBY APPLY for the Governor’s Aid Insurance and declare that the following statements are
true and correct. I agree that this application shall be made as basis in the issuance of ID and benefits by
the Provincial Government of Bohol.

Name (Print Full Name) ______________________________________________________________

Surname First Name Middle Name

Barangay: ADLAWAN Sex: .

Municipality: VALENCIA Civil Status: _________________

Date of Birth:_________________ Place of Birth: _______________

Please check Occupation:

Punong Barangay Barangay Day Care Worker CAFGU
Barangay Kagawad Barangay Health Worker Volunteer Fish Warden
Barangay Treasurer Barangay Livestock Aide LupongTagapamaya
Barangay Secretary Barangay Nutrition Scholar SK Chairman
Barangay Tanod Civilian Volunteers (CVOs)

Designated Beneficiary / ies

NAME Relationship Address

Signed this _________ day of _______________, 2024.

__________________________
Signature of Applicant

Noted:
MAXILINDO T. MAGAN
Punong Barangay

Endorsed by:
DIONISIO NEIL A. BALITE, JD., Ph.D
Mayor

APPROVED:

HON. ERICO ARISTOTLE AUMENTADO

Governor

Endorser:
Punong Barangay Barangay Health Worker Volunteer Fish Warden Mayor
Barangay Kagawad Barangay Nutrition Scholar MHO Civilian Volunteers (CVOs)
Barangay Treasurer
Barangay Secretary MLGOO
Barangay Tanod
LupongTagapamayapa Barangay Day Care Worker – MSWDO CAFGUS – 302nd Brigade
Sk Chairman Barangay Livestock Aide - MAO