Migrant Worker’s Application for Insurance

Personal Information/Personal na Impormasyon

Last Name (Apelyido) First Name (Pangalan) Middle Name (Gitnang Pangalan)

Date of Birth (Petsa ng Kapanganakan) Birthplace (Lugar ng Kapanganakan) Age (Edad) Sex (Kasarian) Civil Status (Pangmamamayang
Kalagayan)

Residence Address (Tirahan) Contact Number

Overseas Employer/Kumpanyang Pagta-trabahuhan

Company Name (Ngalan ng Kumpanya) Occupation (Trabaho)

Business Address (Lugar ng Kumpanya) County (Bansa)

Beneficiaries/Mga Kaanak na Tatanggap ng Benepisyo

Relationship to the Indicate whether the beneficiary is
Full Name (Buong Pangalan) Date of Birth Age (Edad) Proposed Revocable or Irrevocable (Itanda
kung ang kaanak na tatanggap ng
(Araw ng Kapanganakan) Insured(Relasyon sa
benepisyo ay Revocable or
Aplikante) Irrevocable)

______________________________________________ ________________ ___________ _____________________

Revocable
Irrevocable
______________________________________________ ________________ ___________ _____________________

Revocable
Irrevocable
______________________________________________ ________________ ___________ _____________________

Revocable
Irrevocable
______________________________________________ ________________ ___________ _____________________

Revocable
Irrevocable

I hereby apply for Compulsory Insurance Coverage for Agency-Hired Migrant Workers for which I am or may have become eligible,
subject to the terms and conditions of the Group Master Policy. I hereby declare that all statements and answers contained in this
application form together with those statements and declarations stated in any requested medical examination or questionnaire,
which shall form the basis for Pioneer Life Inc. to determine eligibility, are true and complete. I understand that the insurance applied
for will not become effective until the payment of the premium and until this application is approved by Pioneer Life Inc.

Ako ay opisyal na napapahayag ng aplikasyon para sa Compulsory Insurance Coverage for Agency-Hired Migrant Workers, kung
saan ako ay kwalipikado o maaaring kwalipikado, batay sa kataga at kondisyon ng Group Master Policy. Ako ay opisyal na
nagpapahayag ng pagsang-ayon na ang lahat ng mga nakasaad at sagot sa aplikasyong ito, kasama ang mga nakasaad at
deklarasyon sa mga isinumiteng dokumentong medical at palatanungan, na magiging basehan ng Pioneer Life Inc. upang
pagpsiyahan ang aking pagiging kwalipikado sa insurance plan, ay totoo at kumpleto. Ako ay sumasang-ayon na ang aking
insurance plan ay magiging epektibo lamang sa pamamagitan ng pagbayad ng premium at pag-apruba ng Pioneer Life Inc. sa
aplikasyon na ito.

____________________________________________ _________________________________
Signature of Applicant / Date Signed /
Lagda ng Aplikante Petsa ng Paglagda

To be filled up by the Payor/Policyholder/Recruitment Agency/Manning Agency:

Term of Employment: From _____________________ To _____________________ ______________________________

Signature over Printed Name
of Authorized Signatory

“I hereby agree to the recording of all my telephone calls with Pioneer Insurance & Surety Corporation, Pioneer Life Inc. and their
international assistance provider; and authorize them to share these telephone recordings, and any other information obtained
about me among each other, for any purposes relating to the Compulsory Insurance coverage for agency hired migrant workers, or
relating to training and quality assurance.”

____________________________________________ _________________________________
Signature of Applicant / Date Signed /
Lagda ng Aplikante Petsa ng Paglagda

Pioneer Life Inc.|Pioneer Insurance & Surety Corporation

Pioneer House Makati, 108 Paseo De Roxas, Legaspi Village, Makati City 1229, Philippines
MCPO Box 1437, Makati City, Philippines
Tel: +63 2 812 7777 Fax: +63 2 812 2051 www.pioneer.com.ph TIN 005-299-198-000 NON VAT