government ID or two (2) valid non-

Individual Application Form government IDs.

for Group Term Life Insurance DETAILS OF EMPLOYEE/MEMBER

PRU LIFE INSURANCE CORPORATION OF U.K.
REMINDERS: 9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
Please use CAPITAL LETTERS and black ink. 1634 Taguig City, Philippines
Tick the appropriate box to indicate your choice. Customer helpdesk: (632) 8683 9000, (632) 8884 8484, (632) 8887 LIFE
Please do not sign on a blank form. within Metro Manila, 1 800 10 PRULINK for domestic toll-free Email:
If not applicable, put “N/A” in all empty fields. This contact.us@prulifeuk.com.ph Website: www.prulifeuk.com.ph
form should be accompanied by one (1) valid
SURNAME, GIVEN NAME, MIDDLE NAME SALUTATION (e.g. Mr., Mrs., Miss, etc.)

OTHER LEGAL NAME/ALIAS AGE BIRTHDATE (mm/dd/yyyy) BIRTHPLACE (City/Province, Country)

CIVIL STATUS NATIONALITY GENDER Male

Married Female
HEIGHT WEIGHT
ft. in. lbs.
Single
Others
Tick if same as
PRESENT ADDRESS (Number, street, municipality/city, province ) PERMANENT ADDRESS (Number, street, municipality/city, province) present address

COUNTRY ZIP CODE COUNTRY ZIP CODE

NAME OF EMPLOYER/NAME OF BUSINESS NATURE OF WORK OR NATURE OF BUSINESS (if self-employed )

OCCUPATION ( state exact duties; if member of AFP/PNP, state rank ) SOURCE OF FUNDS
Salary Business Others

POSITION GROSS ANNUAL INCOME (in PhP)

NET WORTH (in PhP)

NATURE OF BUSINESS OF EMPLOYER

Tick if same as
EMPLOYER ADDRESS/BUSINESS ADDRESS (Number, street, municipality/city, province ) present address COUNTRY ZIP CODE

sjwnsksisFirelli angel scooter for sale!

80/80 by 14. makapal pa po, no issue kita naman mismo sa picture
DATE HIRED DATE OF REGULARIZATION MONTHLY INCOME TEL. NO.

90/80 by 14. makapal pa po, ang issue lang po is kita naman mismo
sa picture
IDENTIFICATION sa pag kaka
INFORMATION vulcanized lang po pero ayun lang.
SSS/GSIS TIN OTHERS ID NUMBER
loc: brgy holy spirit QC / don antonio commonwealth.
MOBILE NUMBER TELEPHONE NUMBER EMAIL ADDRESS

pm po sa mga interisado.
DETAILS OF PRIMARY AND SECONDARY BENEFICIARIES
If any beneficiary designation is “IRREVOCABLE”, please accomplish the Endorsement for Designating Irrevocable Beneficiary Form. If more than one Beneficiary is named, equal sharing shall be
presumed unless stated otherwise.
SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER Male
Female

RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH (City/Province, Country) NATIONALITY
Primary Secondary Revocable Irrevocable
 SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER Male
Female

RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH (City/Province, Country) NATIONALITY
Primary Secondary Revocable Irrevocable

PRESENT ADDRESS (Number, street, municipality/city, province) ZIP CODE Tick if same as Policyowner COUNTRY

MOBILE NUMBER TELEPHONE NUMBER EMAIL ADDRESS

PRESENT ADDRESS (Number, street, municipality/city, province) ZIP CODE Tick if same as Policyowner COUNTRY

MOBILE NUMBER TELEPHONE NUMBER EMAIL ADDRESS

If there are more than two (2) beneficiaries, please answer the Supplemental Form for Additional Beneficiaries.

STATEMENT OF PHYSICAL CONDITION

1. Are you now in good health and entirely free from material or physical impairments or deformities? Yes No

2. Have you ever suffered or do you suffer from: Yes

a. diseases of the circulatory system (e.g. heart trouble, rheumatic fever, high blood pleasure, diseases of the
Yes No
arteries and veins)?
b. diseases of the respiratory system (e.g. tuberculosis, asthma, persistent cough, pneumonia)? Yes
No
c. diseases of the gastro-urinary system (e.g. infection of the kidney/s, urinary or genital organs, renal stones,
venereal diseases)? Yes No
d. diseases of the gastro-intestinal system (e.g. digestive disorders, gastric or duodenal ulcer, Hepatitis B or other
Yes No
disorders of the liver, disorders of the gall bladder)?
e. diseases of the nervous system or mental disorders (e.g. epilepsy, fits or fainting attacks, frequent headaches,
Yes No
nervous breakdown)?
Yes
f. diabetes, cancer or any diseases of the blood, glands, spleen, ears, eyes or skin? No
g. unexplained night-sweats and/or weight loss, persistent fever, chronic or recurrent diarrhea, unexplained Yes No
infections or swollen glands?
h. any other diseases or ailments not mentioned above? No

3. Have you ever had or been advised to have hospital treatment or surgery? Yes No

4. Have you ever had or been advised to have a blood test for AIDS or AIDS-related condition or have refused as Yes No
a blood donor?

5. Have you ever consulted a physician for any reason, including routine examination and blood tests, or have you Yes No
received a blood transfusion within the past 5 years?

6. Have you ever received or do you now receive disability benefits? Yes No

If you answer “YES” to any of the above questions, please give complete details (including dates, duration and treatment, names and addres ses of
physicians) on a sheet of paper and include your signature.

7. Do you have any application for life insurance that was declined, postponed, or accepted with extra premium? Yes No

AUTHORIZATION TO FURNISH MEDICAL INFORMATION

Pru Life UK is considering an application for insurance on my life and I hereby authorize YOU* or any physician, surgeon, or other person in your or their employ
or who you or they are connected with in any way, or any hospital or other entity, to give Pru Life UK or its authorized medical doctor or representative, any
information which may be desired, and which was acquired while attending to me in a professional capacity. A photographic copy of this authorization shall be
as valid as the original. This authorization is in connection with my application for insurance only.
*YOU refer to the person/party holding or possessing this AUTHORIZATION TO FURNISH MEDICAL INFORMATION.

DECLARATION OF UNDERSTANDING

PLEASE READ CAREFULLY BEFORE SIGNING THIS FORM:

I understand and agree to the following:
1. All the statements and answers in this Application and any information given to Pru Life UK or its medical examiners, including any amendments, are complete, true,
correct,and binding on all parties in interest under the Group Term Life Insurance coverage applied for.

2. Pru Life UK reserves the right to request for additional medical evidence to assess my health. Any physician, hospital, clinic, or medical organization is authorized to
furnish Pru Life UK with any medical information pertaining to me.
 3. Prior to the approval of the insurance coverage applied for, I agree to inform Pru Life UK of any change in my a) state of health, and b) occupation or activities.

4. If a material fact is not disclosed in this Application, the insurance coverage issued may not be valid. I understand that if in doubt as to whether a fact is material, it
will be disclosed to Pru Life UK.

5. The insurance coverage will not commence until the initial premium has been received by Pru Life UK and this Application has been approved while I am alive and in
good health.

6. I will update Pru Life UK in a timely manner of any change in details previously provided, especially with respect to a change in citizenship, tax status or tax residency,
correspondence address, or contact numbers, both local and foreign. If the Policyowner is a corporation, changes in registered address, address of place of business,
substantial shareholders, legal or beneficial owners who own or control more than 20% of the Policyowner will also be disclosed. If any of these changes occur or if
any other information comes to light concerning such changes, I agree to provide additional documents or information that may be requested by Pru Life UK,
including but not limited to duly completed and/or executed (and, if necessary, notarized) tax declarations or forms.

7. I confirm that the the policy details, benefits, and relevant sales materials relating to this Application were received, completely and clearly explained, and fully
understood.

8. The amounts to be invested in this insurance coverage have been declared to relevant tax authorities and were not derived, directly or indirectly, from illegal activities
or sources and/or tax evasion.

9. This Application and any insurance coverage pursuant to it shall be subject to all laws, regulations, resolutions and guidelines on financial underwriting, anti-money
laundering, counter terrorist financing and financial and economic sanctions regimes (“Issuances”). In the event that Pru Life UK is unable to comply with such
Issuances, including the relevant Customer Due Diligence ("CDD") measures as required under the Anti-Money Laundering Act, as amended, due to any act or
omission on my part, Pru Life UK may (i) disapprove this Application; (ii) apply measures to restrict the services available or prohibit any further transactions on the
policy; and (iii) in case such measures are unsuccessful, terminate the business relationship. In the event of termination, any refund of premiums or payment of
withdrawal value shall be subject to the terms of the Policy. I am bound by obligations set out in relevant United Nations Security Council Resolutions relating to the
prevention and suppression of proliferation financing of weapons of mass destruction, including the freezing and unfreezing actions as well as prohibitions from
conducting transactions with designated persons and entities.

10. If this Application is declined by Pru Life UK, its only obligation is to return the premium paid. If the Application is cancelled for failure to submit requirements, Pru Life
UK will return the premium paid less fees for medical examinations it incurred.

11. I accept, agree with, and understand the features, benefits, nature, limitations, exclusions, risks, terms and conditions of the Policy.

12. I agree to receive financial and other policy-related information and notifications through the mobile number and email address I have provided to Pru Life UK.
DATA PRIVACY
For purposes of this Section:
a. “Pru Life UK” shall refer to Pru Life Insurance Corporation of U.K., its directors, officers, employees, insurance agents, insurance brokers, other agents and representatives,
reinsurers, contractors, legal advisers, and Pru Life UK’s subsidiaries, affiliates and other related entities, and their directors, officers, employees, insurance agents, insurance
brokers, other agents and representatives, contractors, and legal advisers.

b. “Data Subject” shall mean the Policyowner, the Life Assured, the Beneficial Owner, Beneficiaries, and all other individuals whose personal information or sensitive personal
information is or will be disclosed to Pru Life UK.
Purpose Statement
The information provided by you in this Application form will be used for general data processing to be done by Pru Life UK for the issuance, implementation and handling of
insurance policies, risk assessment, underwriting and administration of insurance coverage and claims, provision of any service, data analytics, any legitimate interest of Pru Life UK,
or any purpose permitted or required by applicable law. This processing may be either manual or automated and within or outside of the Philippines.

To enable Pru Life UK to effectively address insurance requirements and provide better service, your personal information may also, upon your explicit consent (where required), be
used for profiling, automated decision-making, and direct marketing, which includes products and other offers.

During processing, we may share the information you provided to our authorized data processors to whom we outsource the processing of your information for your Policy,
including couriers and contractors for anti-money laundering systems, claims investigations and processing, risk assessment, photocopying, scanning, indexing and printing
services, and other value-added services.
Our collection and processing of your personal data, including any sensitive personal information, is based on your Application for insurance and other related services, any
contract we may enter into with you, our legitimate interests, or a requirement under applicable law. Any information collected may be retained by Pru Life UK and our
authorized data processors until ten (10) years from the date of maturity or termination of the Policy or date of denial of this Application, whichever comes earlier.

We may share your information with governmental and other regulatory authorities, or self-regulatory bodies in various jurisdictions as required or allowed by applicable laws and
regulations, including the Medical Information Database administered by the Philippine Life Insurance Association, Inc. In accordance with the Insurance Commission’s Circular
Letter No. 2016-54, your medical information will be uploaded to a Medical Information Database accessible to life insurance companies for the purpose of enhancing risk
assessment and preventing fraud. Once uploaded, all life insurance companies will only have limited access to your information in order to protect your right to privacy in
accordance with law. A copy of Circular Letter No. 2016-54 may be accessed at the Insurance Commission’s website at http://www.insurance.gov.ph/.

You are entitled to the following rights: Inform, rectify, object, access, erasure or blocking, damages and complaints. For more information about your rights as a data subject
and how we protect your information, you may access our privacy policy through our website at https://www.prulifeuk.com.ph/en/footer/privacy-policy/. Should you have
any questions or requests in relation to the processing of your personal or sensitive personal information, or your rights as a data subject you may get in touch with our Data
Protection Officer through the following:
Postal address: 9F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio, 1634 Taguig City, Metro Manila

Telephone: (632) 8887 5433 for Metro Manila, 1 800 10 7785465 via PLDT landline for domestic toll-free

Email: dpo@prulifeuk.com.ph
By signing this Application form:

You allow Pru Life UK to use, collect and process your personal information and sensitive personal information as specified in the Purpose Statement above, and in accordance with
applicable data privacy regulations.

You specifically consent to the activities you have checked below:

Automated processing of your personal information which shall be the sole basis of Pru Life UK’s approval or denial of this Application.

Receiving Pru Life UK’s promotional offers via call, email or SMS. You will get up to date information on product features, exclusive products, and other Pru Life UK offers.
You can unsubscribe any time through the contact information provided above.

Using your profile so that we can get a deeper understanding of your preferences and be able to provide you with better products and services.

Sharing by Pru Life UK of your personal information under the Details of Policyowner section of this Application and your policy effective date and premium amount with
Robinsons Bank to avail of the credit card payment facility for your insurance premiums.

• You warrant that the consent of the Beneficial Owner (if any), Beneficiaries, and all other data subjects have been obtained for the use, storage and processing of their
personal information for purposes of compliance with regulatory requirements and applicable laws, the processing of this Application, and the administration of the Policy
issued. You also undertake to provide Pru Life UK with proof of your authority to give the required consents of the other data subjects with respect to the disclosure and
processing of their personal information and/or sensitive personal information for the legitimate purposes set out in this Application or in the Policy issued by Pru Life UK.

• You agree to indemnify Pru Life UK and hold it free and harmless from any damages incurred by Pru Life UK as a result of any claim filed by any of the data subjects in relation
to a breach of any of the warranties above, or for any damages arising from any misrepresentation made in this Application or from any material breach of its provisions.
 EXECUTED AT THIS
PLACE DATE COMPLETED (mm/dd/yyyy)

Signature over printed name of EMPLOYEE/MEMBER Signature over printed name of WITNESS/AGENT

Signature over printed name of IRREVOCABLE BENEFICIARY/IES

CERTIFICATION OF CUSTOMARY SIGNATURE FOR EMPLOYEE/MEMBER

This is to certify that I am the same person who signed the
Individual Application Form for Group Term Life Insurance. I
confirm that the declarations and information therein were
given by me personally and that they are true and complete
to
Finally, I certify that the signature appearing on all my forms
the best of my knowledge.