Application

Hospital Income Benefit Plan

Please send me my Hospital Income Benefit Plan policy. I understand that this does not obligate me in any way that I will have the opportunity to inspect my policy for up to 15 days before I accept it. I understand that the insurance will take effect when my policy is issued and I have paid my first premium during my lifetime and good health.

Plan Information

Source	Facebook
Product	Hospital Income Benefit Plan	Policy Number	HIP-014201-0
Plan	Plan 2000 - Individual	Premium	416.95 Php Monthly

Personal Information

Title	MRS
Name	SEAN	P	RESURRECCION
Birthdate	1983-10-17	Age	34
Gender	FEMALE
Birth Place

Contact Information

Address	27 GREENVILLE HOMES BARORO BACNOTAN LA UNION 2515
Mobile Number	0921-210-5990	Telephone Number
Email Address	SEANRCY@YAHOO.COM

Note: Premiums are based on the age of the policyholder (if single) or the elder spouse at the time the policy is issued. All dependent children from 90 days to 20 years of age are included in the Family coverage. Children's benefits are 50% of parents' benefits.

The Company's liability shall be limited to refund of all amounts paid without interest if the signed enrollment form is not returned to us.

I hereby agree to and/or acknowledge all terms and conditions stated under Data Privacy Consent Statement.

SEAN P RESURRECCION
Applicant's Signature		Date