CC LIFE

C
C
LIFE
TYPE OF LOAN
1. [email protected]
2. Additiond P
3. Renelflal
I)etalle of prorlous loans, Additlonal ard R€nqvd
con$endyfllled out. (Cl banr should be induded)
thotrld be
AyalaAvenueMakatiCity1226
Building,6807
COCOLIFE
MCCP.O.Box 1681.Tel.No.(632)812'9015FaxNo.812-9053.W6bsite:www.cocolife.com
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4.
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b bs}qrd tlp no{nedicel linil thc prE||lum
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paymnts are only consideed ss pFrium dep6|t. Ths clbnt shrll h(b|go mdbal
qaminatbn it his/tFr total $m a$ur€d excaeds th€ n6{rcdi:l
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APPLICATIOI{FORCREDITLIFE INSURANCECOVERAGE
(r{arE oF PoIJCYHoLDERTREDITOR}
GROUPPOLTCY
NO._
APPLN.
NO.
GMDCLIOg3 52 3 42
PERSOT{ALDATA
FIRST
NAME: LqST
MIDOLE
ADDRESS
TESIDENCE
)ATE OF BIRTH
{EIGHT
}IVILSTATUS
IPIACE OF BIRTH
IWEIGHT
TELEPHONE
NUMBER
SEX
JSS& GSIS
TIN
sCCUPATION
IATURE OFWORK
F SEAMAN,PORTOF ENTRY
F OCW / OFW, DESTINATION COUNTRT
II. BETEFICIARY'IES
It is understoodthat the beneficiary/iesshare equally and are designatedas RevocaHe unless otherwise indicated in the 'REMARKS'
NAME
AGE
RELATIONSHIP
REMARKS
OCCUPATION
& R&..ry"rHJ
CITASTAC.FT,,A]\jT
N{II'CTTIS I
CC},FAI.II.1:S
r.'IT;nT-i,lr-)F0-59 Cnnom,{TT\rE
HEALTH DECLARATION
I hereby wanant and dedare lo the best of my knorledge that on the date of tfE releaseof my loan, I am cunenuy well and possesssound health and am aHe to
performthe usual activitiesin the pursut of my livdihood, anclthat:
1. I am in good health and entirdy free from any mental or physicalimpairmentsor deformities.
2. I have not suffered or do now suffer trqn: a) dlsease of the circulatfy system (e.9. heart trouble, rheumatlcfer/er,hilghblood pressure,dlsease.of the
arteries and veins); b) disease of the resFiratqy system (e.9. tuberculosis,asthma, persistent ccugh, pneumonia);c) .diseageof the genito.urinary
system (e.9. infedions of the kidneys.urinary or genilal organs.renal stones. ilenerealdisease);d) disease of tte gastro-iril'estinal
system (e-9. digestive
disorders,gasfic or duodeinalulcer, hepatitisB or other disordersof the liver, disordersof the gall Uadder);e) diseasesof the nervoussystem or mental
disorders (e.9. eftlepsy, fits o fainting attacks, fequent headafies, nervbus.breakdo,vn);0 diabdes, canoer, or arry disease of the blood, glands,
spleen, ears, eyes, or skin; g) unexdained night sweat and or/loss of weight, persistentfever, chronic or recurGnt diarrhea, unexplainedinfections,
swollen glards; h) any other diseasesor ailmentsnot mentionedabove.
3. I never had q been advisedto have hosrital trealmentor swgery.
4. I never had or been advisedto have a bloodtest for AIDS or an AlD$rdated conditiontr have ever been refused 6 a blood donor5. I have not consrlted a physicianfor any reason,includingrouline examinationsand dood tests, or hane receivbdblood transftrsionswithin the past five
(5) years.
6. I have not receivedr now recdve disatility bernfit.
7. ,l have not appliedfor insurancewhich was declined,postponedor modiftedin dan or rate for anylife or disabilitylrBurance.
EXCEPTIOI{STO THE ABOVE
The fdregoingstatement and answers,arefull, completeand true. I agreethat they shall be the basis of the issuanceof insurancefer me under the Grorp Policy
ard the COCPL.ILEshall nqt be liade fr any claim on account of illness, injury, or death, the cause of which was known pior tg approval of my recgest for
insuranceand withhdd or concealedinthe above $atements.
' In as much as I cannot read, write, or urderstand the language, before I afiix my thumbmarks (duly witnessed) to this application,it has
been read and
translaiedto me by the Creditor'sadhorized officer or representative.
IV. AUTHORIZANONTO FURNISHIf,EDICAUOTHERRE-LATEDINFORMATION
|herebyauthorizeanyphy;ician,medica|practitioner/provider,dirdc,hospita|,orottEfmedica||y.re|atedfaci|ity,ir6wanGe-company,[email protected]
or other person, organization,or insUtutionthat has dny record or knowledge of my Medical/HealthHistory and any information relded theretq to give to
COCOLIFEor its HO Undelwdter,Medical Directoi,onany named-rerlresentative,
any such information/records.
This'information'pertdns to all records containing medical or non-medicaldata induding, but not limited tq mental and dental Care, drug or dcohol trse,
prescribeddrugs, informationabout communicablediseaseswhich include, but nd limitedto, human immunodeficiencyvirus (HlV), acquiredimmunodeficiency
syndrome(AIDS) and AIDS rdated comdex (ARC), and any emfloymgnt and insurancecovefage infcrnta$onAso, I hereby authoize [email protected]!
to obtain an
investigativereportfrom a duly aulhorizedinspectionagencywhich wilfprovide any appticableinformationconcerningmy charac{er,generalreputation,personal
characterigics, mode of living, health and financial status tfrough interviewswith friends, neighbors,and associates; and to obtain and make a briCf repod
regardingmy insurat*lityto the MedicalInformaUonBureau (MlB),which operatesas.an inform'ationexchangewith other Life Insuance Cgmparies.
This authorizationis in connectionwith my applicationfor [email protected] any insurancedaim that may arise therefrom.
Signed at
this
day of
20_.
THUMBMARK
Witnessedandissued!y:
Credit./s'Arthortred officer
Signaturoof ,Applicant
'ln €se
GMD-074-0309-1
ol lhteEto AFI€rt