Ultimate Care Card Interntional Insurance Agency Inc.

Home

Services

Full Name:

Surname

First Name

Middle Name

Date of Birth:	Mo.	Day	Year
Date of Birth:

Sex:
Sex:		Male		Female

Place of Birth:

Civil Status :

Height :

Weight :

Nationality :

TIN/SSS/GSIS No.:

Present Address :

Tel No.:

Permanent::

Tel No.:

Name of Employer :

Nature of Work/Occupation:

Nature of Employment/Business :

Card Number :

Beneficiary/ies	Name	Date of Birth	Relationship	Please check appropriate designation
Beneficiary/ies	Name	Date of Birth	Relationship	Revocable	Irrevocable
Primary




Secondary
Secondary

Do you have any previous or existing Group Insurance Coverage with UCCPI? If yes, state Certificate No. Commencement Date:

INSURANCE HEALTH DECLARATIONS:

I hereby represent and declare to the best of my knowledge that:

Im now 18 years old but have not attained the age 65;

I do not have, have never had, nor have I consulted any physician for diabetes, heart illness, high blood pressure, lung or kidney ailment, tumor, cancer or any other physical impairment or complaints, nor have I undergone operation or been hospitalized during the last 5 years; and

I am in good health, able to perform the normal activities in pursuit of a livelihood and free of any physical or mental impairment.

For female applicant: I am not pregnant.

EXEPTIONS:

I hereby declare that all of the foregoing answers and statements are complete, true and correct record. further agree that if there be any fraud or misrepresentation in the above statements meterial to the risk, UCCPI, upon discovery within one year from the effective date of coverage shall have the right to declare such insurance null and void.

Signed at this day of 20


AGENT	Signature over printed Name of Applicant