Skyland Plaza, Sen. Gil Puyat Ave. cor. Tindalo St.

, Makati City
Tel: 580-6856 / 580-6858 | Fax: 815-4797 | email: mira.salas@charterpingan.com

12PLAN APPLICATION FORM

NAME
FIRST NAME MIDDLE NAME SURNAME
HOME ADDRESS
CONTACT DETAILS                  
TEL MOBILE EMAIL
COMPANY
DESIGNATION
EMPLOYEE ID # TIN SSS #
ADDRESSS/BRANCH
CONTACT DETAILS      
TEL MOBILE EMAIL

PLEASE INDICATE THE NAME OF THE OWNER

FIRE INSURANCE APPLICATION (IF DIFFERENT FROM APPLICANT &
RELATIONSHIP)

LOCATION OF PROPERTY TO BE INSURED:

No. Street Name District/Village/Subdivision Town/City Province

Is the property mortgaged? YES NO If YES, with what company?

NAME OF OWNER IF DIFFERENT FROM APPLICANT AND WHY?

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AMOUNT OF INSURANCE TO BE INSURED EXTERNAL WALLS CONSTRUCTED

Building ₱ All Concrete

Contents ₱ Concrete and Timber (Timber is not more than

50% of external wall)

Fire & Lightning Only

Fire & Lightning w/ Allied Perils Full Earthquake Typhoon & Flood Riot, Strike, Malicious Damage

Extended Coverage

EFFECTIVE DATE OF INSURANCE:

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AUTHORIZATION FOR SALARY DEDUCTION

TO : TREASURY / PAYROLL DEDUCTION OFFICER

METROBANK FEDERAL LAND CHARTER PING AN MANILA DOCTORS

PSBANK PHIL. AXA METROBANK TECH FMIC

MCC TOYOTA FINANCIAL TOYOTA MOTORS FMIA

GLOBAL BUSINESS OTHERS (please specify)

I hereby authorize you to deduct from my monthly salary, the 12 Plan monthly premium in the amount of ₱ for the coverage(s) I
applied for, and remit such amount to CHARTER PING AN INSURANCE CORPORATION.

SIGNATURE OVER PRINTED NAME DATE