Manufacturers Life Insurance Company (Phils.) Inc.

AGENT’S SUPPLEMENTAL REPORT

(GROUP BUSINESS)

MARY CAR F. FABULARUM

Name of Agent : __________________________________ Agent’s Code : ________________
376045
DONA TIGULO
Name of Manager : ________________________________ STELLAR ATLANTIS AQUALITH
Branch/Unit : _________________
Tel. No. / Contact Nos.: 09309249371 FINANCIALS

Below are several questions that need to be answered in order for us to properly evaluate the risk
involved. Answer all questions as completely as possible.

LAWIGAN NATIONAL HIGH SCHOOL

1. Full Legal Name of Applicant __________________________________________________

LAWIGAN SAN JOAQUIN , ILOILO

2. Business Address ___________________________________________________________

__________________________________________________________________________

3. Plant Address, if any _________________________________________________________

N/A

__________________________________________________________________________

EDUCATION
4. Nature of Business (Give details) _______________________________________________

__________________________________________________________________________

N/A
5. What is the main product/service? _______________________________________________

6. Where do they operate? _______________________________________________________

N/A

N/A
7. Are there any hazardous tasks performed by any of the employees? ____________________

___________________________________________________________________________

N/A
8. How many employees? _______________________________________________________

Give the details of the different occupations :

POSITION DETAILS OF OCCUPATION

1.
2. N/A
3.
4.
5.
6.
Note : Use reverse side if necessary.

To the best of my knowledge. I hereby certify that the above statements and answers are true
and complete.

____________________________________ ______________________
Signature of Agent Date

=========================================================================
(FOR GROUP INSURANCE DEPT. USE ONLY)

______ Approved for processing

______ Disapproved Reason : _____________________________________

___________________________ ___________________
Signature of Approving Authority Date