10/F Allied Bank Center, 6754 Ayala Avenue corner Legaspi Street, Makati City, Philippines Tel. No. 818–LIFE (5433) • TIN No. 204-145-589-000

ENROLLMENT FORM FOR MEMBERSHIP IN THE GROUP MORTGAGE REDEMPTION INSURANCE PLAN (PART 1)
Surname First Name Middle Name Date of Birth Gender

Male Female
Nationality Place of Birth Civil Status Single Divorced Widowed Height Married Separated Telephone No.: Cell Phone No.: Weight

Residence:

Address

Business/Office:

Fax No.:

E-mail Address:

Occupation / Position: (Please give details)

Name of Company:

Nature of Loan:

Amount of Loan:

Term of Loan:

Beneficiary/ies: The amount of insurance in force at the time of death and not exceeding the maximum amount specified therein shall be made payable to my Creditor (the Primary Beneficiary) __________________________________________ and applied accordingly to reduce or extinguish my obligation. Any excess amount of insurance shall be granted to my secondary beneficiary/ies, which will share equally and are revocable unless indicated otherwise in the “REMARKS” column. Relationship Remarks Name of Secondary Beneficiary/ies Date of Birth (First) M.I. (Last) MM DD YY

Designation of Trustee (We suggest that you designate a trustee for minor beneficiaries to facilitate claim settlement). I hereby designate: Name of Trustee Relationship to Applicant as a trustee of the minor beneficiary/ies named above. He is authorized to receive for and behalf of said beneficiary / ies any insurance proceeds due during the minority of the said beneficiary/ies. The receipt of said trustee of the insurance proceeds due to the minor beneficiary/ies shall discharge the liability of the Company with respect to the amount so paid. Additional Information: 1. Have you ever had or been treated to any of the following: Heart attack, angina pectoris or arteriosclerosis? Cancer, tumor, diabetes, high blood pressure, paralysis or ulcer? Any disease of the heart, lungs, brain, liver, stomach or kidneys? 2. Have you ever: Been declined, postponed or modified in plan or rate for any Life or Disability Insurance? In the past two (2) years lost more than fifteen (15) consecutive days from work due to illness, injury, hospital or sanatorium care? Had any other illness, surgery or hospital care in the past five (5) years? 3. Have you ever been counseled or medically advised or treated in connection with an HIV infection, AIDS or any Sexually Transmitted Disease? 4. Are you engage in any scuba or skin diving, motorcycle, car, motorboat racing or any other extreme sports / hazardous avocation? 5. Are you active or engage in politics as leader or candidate?

Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No

If you answered “yes” to any of the above questions, please give complete details (including dates, duration & treatment, names, addresses of the physicians) on the back of this form. I hereby declare that to the best of my knowledge and belief the statements that I have made hereon are true and complete and that I am currently well and in sound health. I consent to PNB Life Insurance, Inc. seeking medical information from any doctor who at any time has attended me concerning anything which affects my physical or mental health or seeking information from any insurance company to which a proposal has been made for insurance on my life and authorize the giving of such information. I further agree that if within one (1) year from the date of this declaration, any of the foregoing statements are found to be untrue in any respect, PNB Life Insurance, Inc. shall have the right to declare null and void and to revoke the above-mentioned policy. Signed at _______________________________________ this _____________________ day of _____________________________, 20 __________________ .

Printed Name and Signature of Applicant
GMRI Enrollment Form_2010