Group Name:

Address:
Total Group Size:
Annual Premium/Pax:
Total Premium:
Effective Date: (policy to commence
upon receipt of the declaration and proof of
payment)

The FORM is not the covering certificate. This shall serve only as a Masterlist for Group Registration Coverage. Signatures validate the coverage.

MEMBER / INSURED’S DETAILS BENEFICIARY

(LEGAL SPOUSE, CHILD, RELATIONSHIP TO THE
# LAST NAME FIRST NAME PRESENT HOME ADDRESS OCCUPATION AGE BIRTHDAY
PARENT, SIBLING) PRINCIPAL INSURED
1
2
3

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

Page 1 of 2
25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

Page 2 of 2