Online Purchase Form | Life Plans Philippines

Application

Branch

Plan Type

Mode Of Payment

Preferred Payment Option

Total Contract Price

Total Amount payable

Are you between 18 to 65 years of age?

Yes

Installment Due Date

Last Name

First Name

Middle Name

Suffix

Date of Birth

Age

Height(inches)

Weight(kilograms)

Home Address

Office Address

Mailing Address

I Prefer to pickup the contract at the nearest Golden Future office (Policy Contract is delivered to mailing address by default.)

Home Address

Office Address

Place of Birth

Nationality

Sex

Male

Female

Occupation

Status of Employment

Employer Name/ Name of Business

Civil Status

Tin

SSS/GSIS NO.

Mobile No.

Landline No.

Email Address

Source of Sale

Source of Income

Beneficiary 1

Name

Age

Relationship to Planholder

Address

Beneficiary 2

Name

Age

Relationship to Planholder

Address

Beneficiary 3

Name

Age

Relationship to Planholder

Address

Beneficiary 4

Name

Age

Relationship to Planholder

Address

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Name of Sales Associate

Health Declaration Statement

The applicant who is at least eighteen (18) years old but not over sixty-five (65) years of age at the inception of the plan and is physically and mentally able to perform the usual and normal duties of their occupation shall be eligible under the Company's Group Insurance.

No applicant will be covered under the plan unless coverage is endorsed and is duly approved by the Company's Group Insurance.

The applicant has not consulted any physician for heart condition, hypertension, cancer, diabetes, lungs, kidneys or intestinal disorder, tuberculosis, or any other physical impairment nor has been confined in a hospital/ clinic and received any medical or surgical attention. If so, kindly give results:

I agree that this application form shall be the basis for the Insurance coverage issued under the Company’s Group Insurance. I understand further that the insurance coverage shall not become effective until it is accepted and confirmed in writing by the Company’s Group Insurance.

It is understood and agreed that the issuance of the plan is based on the truth of the stated representations. Any false statement of the applicant as to his/her age or health may render the Life Plan Contract rescissible. The undersigned further agrees that this contract and the declaration given above shall be the basis of the contract between the undersigned applicant and the company and shall be deemed to be an integral part of the contract, subject to the conditions stated in the Life Plan Contract.

I understand and agree to the statement above

I hereby consent to the collection, use and disclosure by the Seller of all the personal information I have given hereunder for the purpose of processing this Life Plan Application Form and all other documents related hereto

Please acknowledge and agree above.

Sign Signature Here

Electronic Signature

Mobile Wallet

Choose from the following:

All Easy

GCash

Paymaya

Grab Pay

Transaction Date

Transaction Amount

Attach copy of successful payment confirmation.

Online Banking/Fund Transfer

Choose from the following Golden Future Life Plan Banks:

ALLBANK

BDO

SECURITY BANK

EASTWEST BANK

BPI

UNIONBANK

Transaction Date

Transaction Amount

Attach copy of successful payment confirmation.

Payment

Card Number

Expiry Year Ex: 2023

Expiry Month Ex: 10

CVC

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Confirmation

Please check if the details below are correct.

Plan Specifications

Branch:

Plan Type:

Total Contract Price:

Mode Of Payment:

Total Amount payable:

Installment Due Date:

Insurable:

Plan Holder's Personal Details

Last Name:

First Name:

Middle Name:

Suffix:

Date of Birth:

Age:

Place of Birth:

Nationality:

Sex:

Civil Status:

Height (inches):

Weight (kilograms):

Occupation:

Status of Employment:

Employer Name/ Name of Business:

Tin:

SSS/GSIS NO.:

Mobile No.:

Landline No.:

Email Address:

Home Address:

Office Address:

Mailing Address:

Beneficiaries

Beneficiary 1: N/A

Age: N/A

Relationship to Planholder: N/A

Address: N/A

Beneficiary 2: N/A

Age: N/A

Relationship to Planholder: N/A

Address: N/A

Beneficiary 3: N/A

Age: N/A

Relationship to Planholder: N/A

Address: N/A

Beneficiary 4: N/A

Age: N/A

Relationship to Planholder: N/A

Address: N/A

Others

Source of Sale:

Source of Income:

Preferred Payment Option: Online

Name of Sales Agent:

Attachments

Attached Valid ID:

Electronic Signature: