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Application

This document is an application form that collects personal information from the applicant, including their name, birth date, gender, contact details, and occupation. It also includes sections for beneficiary details and plan options, along with terms and conditions regarding service misuse. The applicant must sign and date the form to agree to the terms outlined.

Uploaded by

zaynthecreater
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
3 views1 page

Application

This document is an application form that collects personal information from the applicant, including their name, birth date, gender, contact details, and occupation. It also includes sections for beneficiary details and plan options, along with terms and conditions regarding service misuse. The applicant must sign and date the form to agree to the terms outlined.

Uploaded by

zaynthecreater
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

Application Form

General Questions

Proposed Inquire d’s Name:


(Please use Capital Letters)

Birth Date: ____/______/_____Gender Male Female Passport no:___________


Address: __________________________________________________________________________
:
Phone Number: ___________________________ Email Address: _________________________
ID Number: __________________________ Social Security Number: _____________________
Status: Single Married Divorced Others
Occupation:__________________________ Are you a retiree? Yes No

Personal Details
Name of Beneficiary:
Bank Account(or ID number for Confirmation only):
Name and Address Of beneficiary’s bank:

Employee Yes No Spouse Yes No Child Yes No

PLAN A PLAN B JOIN NOW !


Misuse of the service may lead to Misuse of the service may lead to
restricted access or account restricted access or account
termination. termination.

The Policy
Units: _______________________________ Account Premium: ______________________________
Payment Mode Annual Semi-Annual Monthly PAT (complete PAT cord)
Cost with application: $________________________________________________________________
Planned Model Premium: $_____________________________________________________________

signature
Terms and conditions
By using our services, you agree to follow all applicable guidelines X
and policies. Misuse of the service may lead to restricted access or
Date:_____________________
account termination.
_

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