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Enrollment Short Form For Group Insurance

The document is an individual enrollment form for group insurance that collects personal information such as name, birthdate, contact details, employment information, and beneficiary designation for life insurance from Ira Angelo Cordero. It provides his biographical details, residence, employer, and names his mother Caiden Cordero Sumilong as his beneficiary. The form is signed by Cordero to certify the accuracy of the provided personal data.

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Ira Angelo Cordero
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556 views1 page

Enrollment Short Form For Group Insurance

The document is an individual enrollment form for group insurance that collects personal information such as name, birthdate, contact details, employment information, and beneficiary designation for life insurance from Ira Angelo Cordero. It provides his biographical details, residence, employer, and names his mother Caiden Cordero Sumilong as his beneficiary. The form is signed by Cordero to certify the accuracy of the provided personal data.

Uploaded by

Ira Angelo Cordero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Insurance Enrollment Form

Individual Enrollment Form for Group Insurance

Personal Information
Last Name First Name Middle Name
FOR PIONEER LIFE USE ONLY
Cordero Ira Angelo Sorilla
Birthdate (mm/dd/yyyy) Birthplace Age Sex Height Weight Group Policy No.

03/17/1988 Manila 35 Male 5'5 70kls Certificate No.

Residence Address Civil Status Nationality Effective Date

B.47 L.21 Ph.3 Fluorine St. Golden City Anabu 2F Imus, Cavite
Single Philippines
Amount of Insurance:
Contact Number(s) SSS/GSIS Number Tax Identification Number (TIN)
9360847902 34-1870156-1 287-116-503 Basic Life

Name of Employer/Association/Creditor Occupation/Position Accident


TPD
IGT Technologies Philippines Inc. Travel Associate
Bereavement
Date of Employment/Membership/Loan Term of Loan (if Group Credit Life) Amount of Loan (if Group Credit Life)
Approval (mm/dd/yyyy) Others
07/14/2023 N/A N/A (pls. specify)
Beneficiary Designation
Full Name (Last, First, Middle) of Beneficiary(ies) Birthdate (mm/dd/yyyy) Age Relationship to Insured
Cordero, Caiden, Sumilong 06/15/1956 12 Mother

I hereby certify that the personal data contained herein are true and correct.
Electronically signed by: 07/12/2023
Ira Angelo Cordero
Signature over printed name of applicant Date (mm/dd/yyyy)
PIONEER LIFE INC.
Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph

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