SAFE TRIP APPLICATION FORM

1. POLICYHOLDER DETAILS (should be one of the travelers)

1.1 Last Name 1.2 First Name 1.3 Middle Name
Tapayan Ana Marie Agbu

1.4 Birthdate (MM/DD/YYYY) 1.5 Age 1.6 Sex 1.7 Nationality 1.8 Civil Status
30 June 1962 61 Female Filipino Widow

1.9 Usual Place of Residence (address must be in the Philippines)

35 Monroe St., Don Antonio Royale Estates, Matandang Balara,Quezon City

1.10 Contact Number/s 1.11 Mobile No. 1.12 E-mail Address 1.13 Occupation
+639222019994
anamarietapayan2022@gmail.com Retired

1.14 Government I.D.

Passport # P6690985C

2. FOR FAMILY PLAN

Complete Name Birthdate (MM/DD/YYYY) Relationship Government I.D.
(Spouse)
Deceased

(Child 1) Claudine Tapayan 17 February 2024 Daughter

(Child 2)

(Child 3)

(Child 4)

(Child 5)

Note: For Family Plan, minimum of three persons maximum of six, travelling together.
3. TRIP DETAILS
3.1 Single Trip Policy 3.2 Annual Policy
Worldwide 2.5M Worldwide 1M ASEAN Plus Domestic Plan 1 Plan 2 Plan 3

3.3 Departure Date (MM/DD/YYYY) 3.4 Return Date (MM/DD/YYYY) 3.5 No. of Days
22 May 2024 11June 2024

3.6 Purpose of Trip 3.7 Destination/s

Business X
Leisure Others Italy

4. CONTACT IN CASE OF EMERGENCY

Name Contact Number/s and Email Address
Stephen Arapoc 09173017317

5. HEAD OFFICE ENDORSEMENTS (to be accomplished by Pioneer personnel only)

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I certify that all information contained in this application is true and complete to the best of my knowledge; I agree that:
• this will form part of the contract of insurance;
• the policy becomes valid and binding only upon receipt of the Premium due and upon approval for issuance by Pioneer Insurance & Surety Corporation;
• claims arising from pre-existing conditions, among other exclusions under the contract of insurance, are not covered;
• no information is binding on Pioneer Insurance & Surety Corporation unless stated in this application or in any related amendments;
• I shall advise Pioneer immediately in case of an emergency and/or before being discharged from a hospital thru any of the hotline numbers:
+63 2 8172021 (Manila), +6 03 27725769 (Kuala Lumpur);
• I authorize Pioneer Insurance & Surety Corporation, its subsidiaries and affiliated companies to use my contact information to advise me of their respective
promos, special offers or other products; and
• when I accept the policy/ies issued on this application, I ratify any entries made by Pioneer to correct any errors or omissions.

Authorization to Furnish Medical / Other Related Information

I/We hereby authorize any legal parties/entities, who collect, hold, process or use any of my/our personal information, to provide Pioneer Insurance
& Surety Corporation its reinsurers or any of its authorized affiliate or representative with, and for any of the latter to collect, retrieve, use and/or
otherwise process, or to disclose, provide or furnish to other insurance company(/ies) and their affiliates or representatives, any of my/our personal
information, sensitive personal information and privileged information, including copies (original or certified) of documents, relating to my/our health
and personal identity necessary in any underwriting process and in the evaluation of any claims under this policy to be conducted by Pioneer Insurance
& Surety Corporation or for any legitimate purpose.

It is understood and agreed that any action which these legal parties/entities may take in connection with this authorization, releases said parties or
entities, or any and all members of their staff from any responsibility or obligation in connection with the release or processing of such records or
information.

This authorization pertains to this application only. A photocopy of this authorization will be considered as valid as the original.

I/We hereby certify that I/we have carefully read and clearly understood all of the above said agreements, declarations and authorizations, and do hereby
voluntarily accept and acknowledge the same as informed expressions of my/our own free will.

4/15/2024

Signature over printed name Date and Place Signed Signature over printed name
of Applicant of Intermediary

PIONEER INSURANCE & SURETY CORPORATION

Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph Page 2 of 2