Republic of the Philippines

1x1 Department of Finance

ID INSURANCE COMMISSION
PHOTO
APPLICATION OF INSURANCE AGENTS’
WALK-IN EXAMINATION

1. Full Name: __________________________________________________________________________

(First Name) (Middle Name) (Surname)
2. Address: _________________________________________________ Tel. No.: ___________________
3. Place of Birth: __________________________ Date of Birth: ________________ Sex: __________
4. Citizenship: _______________ Civil Status: _____________ Occupation: ______________________
5. Have you ever been discharge from any position (YES/NO)? ________________________________
If so, state particulars _________________________________________________________________
6. Have you ever been convicted of any crime (YES/NO)? ___________ If so, attach decision of court.
7. Have you ever been granted a license or certificate of authority to act as insurance agent/variable
life agent/general agent in this country (YES/NO)? _____________.
If yes, state name of insurance company represented ______________________________________
8. Kind of examination applied for (Life/Variable/Non Life): ____________________________________
9. Insurance company represented: _______________________________________________________
10. Date of Application: ___________________________________________________________________

________________________________________________
Applicant’s Customary Signature
TIN ________________ Res. Cert. # _________________

PROCESSED BY: ____________________________ APPROVED BY: _____________________________

OR # _____________________ DATE ________________________

IC-LLI-DP-001-F-01
Rev.0

Republic of the Philippines

Department of Finance
1x1 INSURANCE COMMISSION
ID
PHOTO APPLICATION OF INSURANCE AGENTS’
WALK-IN EXAMINATION

6. Full Name: __________________________________________________________________________

(First Name) (Middle Name) (Surname)
7. Address: _________________________________________________ Tel. No.: ___________________
8. Place of Birth: __________________________ Date of Birth: ________________ Sex: __________
9. Citizenship: _______________ Civil Status: _____________ Occupation: ______________________
10. Have you ever been discharge from any position (YES/NO)? ________________________________
If so, state particulars _________________________________________________________________
11. Have you ever been convicted of any crime (YES/NO)? ___________ If so, attach decision of court.
12. Have you ever been granted a license or certificate of authority to act as insurance agent/variable
life agent/general agent in this country (YES/NO)? _____________.
If yes, state name of insurance company represented ______________________________________
13. Kind of examination applied for (Life/Variable/Non Life): ____________________________________
14. Insurance company represented: _______________________________________________________
15. Date of Application: ___________________________________________________________________

________________________________________________
Applicant’s Customary Signature
TIN ________________ Res. Cert. # _________________

PROCESSED BY: ____________________________ APPROVED BY: _____________________________

OR # _____________________ DATE ________________________

IC-LLI-DP-001-F-01
Rev.0