MAPFRE Insular Insurance Corporation

v.22_07
MAPFRE Insular Corporate Center
Acacia Ave., Madrigal Business Park
Ayala Alabang, Muntinlupa City 1770
Metro Manila, Philippines
T: (+63) 8876 4444 ; F:(+63) 8876 4443

Travel Insurance - International Application Form www.mapfre.com.ph

THE PROPOSAL FORM SHOULD BE COMPLETED TO THE BEST OF YOUR KNOWLEDGE AND BELIEF AND ALL MATERIAL FACTS SHOULD BE DISCLOSED. FAILURE TO DO SO MAY NULLIFY COVER
UNDER ANY POLICY ISSUED. A material fact is one that is likely to influence the insurer’s acceptance or assessment of the proposal. You should consult MAPFRE Insular Insurance Corporation
if you are in any doubt as to what constitutes a material fact.

CLIENT INFORMATION

For Individual Client

Last Name First Name Middle Name
Rosales Frederick Balace
Present No./St. District/Town City/Province Zip Code
Address 14 Syjuco Street BF Homes Paranaque City 1718
Permanent No./St. District/Town City/Province Zip Code
Address
Nationality Date of Birth (mm/dd/yyy) Place of Birth
Filipino/American 03/31/1967 Manila, Philippines

Civil Status ✔ Single Married Widowed Gender ✔ Male Female Email

SSS/GSIS No. TIN Cellphone No. Landline No.

09192538133
Nature of Work Source of Funds Net Income Rank Non-officer Junior Officer Senior Officer
Physical Therapist Savings N/A (Supervisor-Manager) (AVP & Up)

Name of Employer
EMPLOYER/BUSINESS FOR THE LAST FIVE (5) YEARS HOUSE OCCUPIED
N/A
Name Period Covered Owner’s Name
Self-employed Alidia Rosales
Name of Business/Self-Employment Lesse’s Name (if rented)
Home Care Physical Therapy

Name of Beneficiaries (if applicable) No. of children depending for support (if applicable) Car/s owned (if applicable)
Patrick Jason Rosales Honda Mobilio
Banks (where accounts are maintained) Type of Bank Accounts Other assets: Real/Personal
PNB Savings

TRAVEL DETAILS
Purpose of Trip
Business Trip (i.e. Seminar, Conference, etc.) Vacation/Leisure Study/Training ✔ Visiting Relatives Others (Please sepcify)
Complete Itinerary (Kindly list of origin and all destination for the trip)

Departure Date (mm/dd/yyy) Arrival Date (mm/dd/yyy)

05/22/2023 05/31/2023

INSURANCE PLAN
Travel Insurance Coverage Coverage Options
✔ Individual Assist only ✔ with Personal Accident (PA) Cover with PA Cover and Liability Cover

Family Medical Expense Coverage

USD 20,000.00 ✔ USD 45,000.00 USD 50,000.00 USD 100,000.00 EUR 35,000.00
(Applicable for Schengen Travels only)
Extension of Coverage
✔ Covid19 Coverage Cruise Inclusion Hazardous Sports Inclusion Sports Equipment Inclusion (Please specify on the next page)
NOTE: Age eligibility for COVID 19 extension for Asia and World travel is up to 64 years old only and up to 75 years old for Schengen Travel
Please select
For Family Coverage List of Beneficiaries (Proceed to item no.2 below. No need for Passport Number and Physician Details)

NAME BIRTHDATE RELATIONSHIP TO THE PRIMARY USUAL PHYSICIAN

PASSPORT NO.
(Surname, First Name, M.I.) (MM/DD/YYYY) INSURED (Name & Contact No.)

1. Rosales, Frederick B. 03/31/1967 PRIMARY / PRINCIPAL INSURED A00979070 Dr Justo Cammayo 09178335878
2.

3.

4.

5.

6.
 Travel Insurance - International Application Form

SPORTS / EQUIPMENT DECLARATION (Please match your item number on the previous page)
ITEM ARE YOU PLANNING TO ARE YOU CHECKIN IN ANY
IF YES, PLEASE SPECIFY SPORTS ITEM NO.
NO. ENGAGE IN ANY SPORTS? SPORTS EQUIPMENT?

1. YES ✔ NO YES ✔ NO

2. YES NO YES NO

3. YES NO YES NO

4. YES NO YES NO

5. YES NO YES NO

6. YES NO YES NO

PAYMENT INSTRUCTION

- Check (✓) appropriate boxes. Cash

- Cheque payments should be made payable to MAPFRE Check
Insular Insurance Corporation. Please write your invoice number at
the back of the cheque. Bank/branch ______________________________________________________

- Payments can be made thru the following: Check no. ________________________________________________________

 Bank – Over the counter for BPI, BDO, Unionbank
Bank / Over-the-counter On-line & Mobile Biller
and Security Bank
 On-line & Mobile Biller – Visit the website or BPI BDO Unionbank Security Bank Branch _________________________
download the bank’s mobile app
ATM (Security Bank)
 ATM – Available on Security Bank ATM Machines
only GCash
 Gcash/Maya – Log-in to Gcash or Maya app
Maya
 Bayad– Through the app or through authorized
partners Bayad Center
 Debit/Credit Cards – through MIVO or the Credit Card Visa Mastercard via M.I.V.O. or MAPFRE E-payment Portal
E-Payment Portal in the website or by visiting
any MAPFRE Insurance Sales Office Debit to Account

- Please ask for a PROVISIONAL RECEIPT if payment is Bank/branch ______________________________________________________

made to persons or entities other than the company’s cashiers. An
Account No. ______________________________________________________
OFFICIAL RECEIPT will be mailed to you at the earliest date. Please
notify the company if you do not receive the Official Receipt in 30 Others ________________________________________________________________
days.

ACKNOWLEDGEMENT & AGREEMENT

Certified True and Correct

By submitting details herein, I hereby indicate my conformity to the use and storage of the data as identified above. Including the sharing of the same to
MAPFRE Group of companies, it’s contractors and/or sub-contractors for legal purposes. If transacting and/or acting in behalf of other person/s, I hereby
warrant that I am duly authorized to transact in the latter’s behalf and to give information provided on this form.

I/We further declare & warrant that the above statements are true & complete; I/We consent to the insurers seeking medical information from any Doctor
who has at any time attended concerning anything which affects my/our physical or mental health. I/We agree that this proposal shall form the basis of the
contract should the insurance be affected. I am/We are willing to accept the Policy, subject to the terms, exception & conditions prescribed by MAPFRE
Insular Insurance Corporation, therein.

I HEREBY DECLARE THAT:

1. I/We will not be traveling against the advice of a physician.

2. I am/We are not on waiting list for any medical treatment.
3. I/We will not be traveling for the purpose of obtaining medical treatment.
4. I/We have not received a terminal prognosis for a medical condition before this day.
5. I am/We are in good health & condition and I/we understand that any pre-existing illness (known & unknown) shall not be covered.

Position & Contact no. (for Corporate Clients only) ___________________________________

FrederickRosales
___________________________________________
07/17/23
______________________ ___________________________________________
Applicant’s signature over printed name Date Policy No.

REFERENCE QUOTE NO.