SlideShare a Scribd company logo
1 of 1
Download to read offline
CtIMBS LIFE AND GENERAL INSURANCE COOPENATIVE
CtIMBS Bldg.. Zone 5, National Hi€hway, Butua, 9O00 Cagayan de Oro City, philippines
TelephonelFax Nos.: (o8822) 738738; {OsB} 9s61355 Email: head*office@climbs.cooF
- *^ rfi
INDIVIDUAT APPLICATION FOR GROUP INSURANCE N: IU
Application No.
Fremiurn
Amount sf lnsurance
(Cooperative, Assdciofrbfl, Lefidiftg, Frafessia$*ls, Ssci,rnly gusrds. etc.l
7 41001
foop Loan Protecti0n Plan - CIPF
Name oi Group
Graup Type
Group/Employer Name
Natura pf WorklEn$loym€ntlSourrc of Fund
Other GrpuF Mernbershlp [ 1]
Preient Address
purro"nunt sii."r. 0 " P" Ri >al .Pos'orq P i
q D.rsra(?L
Last Nam€
DatP Df
Type I tprivare I lceernnenr { ]Retiremenr I isell Fmptowd I lorheri_
HE*IT}I BECLAftATIOII TOBM
Please answer each of the foltowing questions in full disclosure/utmost good faith. Check in the box Brovided for details, provide particulars if available
{such as existin* clinica} records}.
l'. Are you aware of any health disorder or advice from doctor that you are suffering from any:llfless- ----- I lyES t4Nc
lf YES, please specify _
Are you in gcod health and entirely lree frorn any mental or physical impairrnent and/or deformlli6l----*..-*- -------- [ ]yf;T7?;6
If YES, please speciry
1.
3.
5.
6, Are you taking medicarion of any kind? tf yES. for what? i/ivrS f trrio
Are you taking medication of any kind? tf YES. for what? i/wr* r r*..t
Please provide the name/address and the telephone number of yc,ur attending phyrician
I DECIARE, that the above arswers are true and correct, and I agree that these shall be the basis of the isruance of lnsurance for me under the Group
Policv and that CLIMBS shall ftot be liable {or any claims on account nf illness, iniury or death, the cause of which was known prior to *pproval of my
request for insuranre and u/ithheld or concealed in th€ above statenreilts. I hereby authoriz€ any physician, doctors. hospital, clinic, that has any
knowledge of rny medical records to disclose when request*d to do so by CtlMBS. I UHDERSTAND that diqualtfication {r$m eoyErago wlll efi;tla me
only to refund of premium without interest.
signecat
-PITQ&
.6y9?g) .
--.
. rhis to r)
Narfie & Signature of Authorized Sfficer
FON TOAN OFF'CER UsT OilLY
Name of Group LoanStatusi )fVew ( ) Renewaj
& Signature/Thumb mark of Applicanr Mernber
Amount of Loan Granted
Date Releas€ Term of Loan {months) Maturity Date
Fremium Due Term of lnsurance Coverage Paid (months)
Name'and Signatr;re oi Loan Officer Name and Signature of Applicant Menrber
ereditor
CLIMBS LIFE AFID GENERAL I$ISURANCT CO$PERATIVE
tIMBs Bldg., Zane g. {;tioa6} f,t€hwav. EEtua. ,OO0 Cl8ayan d€ Oro Ctty, phiiippines
te,eFhone/aat ilos.. i0$8221 7f87l8i loa8i 8561:55 Em&]r head-sili.e€€liHbr.rep
CONTiRMATION OT SOVEffIGE
CLIMES Life and General lnsurance Cooperative certifien that it hi6 in*ured the follor*ing perron,/s:
lnsured Memher
Beneficiarylies
Expin{ OatE: Amcunt of lnsurance: Pr€mium:
Group Policy No.:
Effective Sate:
ln atcordance wjth the provisions ef the Master Policy, CLIMBS will pay to the lnsured Member or Eeneficiary/ies of the lnsured Member rhe face
amaunt of the benefits as found irr the Schedule of Senefits up te the maxiffiufi afiount ifi the Mast€r Policy, promptly upon receipt of satisfactory
proof of claims.
This certificate will in no way void any s{ the provisions in the Master p*licy"
Coop Lrran Protection Pla$
Nrl$744BSl
lssue Date
Narne and Signature of Authorieed Officer

More Related Content

Similar to ERWIN SUAREZ20230323 CLIMBS LIFE.pdf

Health Insurance Proposal Form - HDFC ERGO
Health Insurance Proposal Form - HDFC ERGOHealth Insurance Proposal Form - HDFC ERGO
Health Insurance Proposal Form - HDFC ERGOSaurav Mishra
 
UB04 EXAMPLE JONES
UB04 EXAMPLE JONESUB04 EXAMPLE JONES
UB04 EXAMPLE JONESEbony Holden
 
KandaMyrvik Workers Compensation
KandaMyrvik Workers CompensationKandaMyrvik Workers Compensation
KandaMyrvik Workers CompensationKanda Myrvik
 
KandaMyrvik TRICARE
KandaMyrvik TRICAREKandaMyrvik TRICARE
KandaMyrvik TRICAREKanda Myrvik
 
SEC Filing: SV Angel is raising a fifth, $70M fund — its largest to date
SEC Filing: SV Angel is raising a fifth, $70M fund — its largest to dateSEC Filing: SV Angel is raising a fifth, $70M fund — its largest to date
SEC Filing: SV Angel is raising a fifth, $70M fund — its largest to dateHarrison Weber
 
Revival of Lapsed Policy Forms Fno 680
Revival of Lapsed Policy Forms Fno 680Revival of Lapsed Policy Forms Fno 680
Revival of Lapsed Policy Forms Fno 680Indialic .in
 
KandaMyrvik Medicaid
KandaMyrvik MedicaidKandaMyrvik Medicaid
KandaMyrvik MedicaidKanda Myrvik
 
Health insurance claim | Health Care Domain
Health insurance claim | Health Care DomainHealth insurance claim | Health Care Domain
Health insurance claim | Health Care DomainH2kInfosys
 
Health Suraksha Health Insurance Claim Form - HDFC ERGO
Health Suraksha Health Insurance Claim Form - HDFC ERGOHealth Suraksha Health Insurance Claim Form - HDFC ERGO
Health Suraksha Health Insurance Claim Form - HDFC ERGOSaurav Mishra
 
QuarterlyV64N2-cover-to-cover
QuarterlyV64N2-cover-to-coverQuarterlyV64N2-cover-to-cover
QuarterlyV64N2-cover-to-coverMike Olsen
 
maternity leave form.docx
maternity leave form.docxmaternity leave form.docx
maternity leave form.docxEleinMRosinas
 
medical re imbursement application forms,new hospitalsand full government o...
medical re imbursement application forms,new hospitalsand  full government  o...medical re imbursement application forms,new hospitalsand  full government  o...
medical re imbursement application forms,new hospitalsand full government o...shanavas chithara
 
Professional liability insurance application for medical director’s
Professional liability insurance application for medical director’sProfessional liability insurance application for medical director’s
Professional liability insurance application for medical director’sevaj171
 
How to Initiate a Life Insurance Claim
How to Initiate a Life Insurance ClaimHow to Initiate a Life Insurance Claim
How to Initiate a Life Insurance ClaimBankBazaar.com
 
Proposal form form300
Proposal form form300Proposal form form300
Proposal form form300smservices
 
Understanding New York No Fault
Understanding New York No FaultUnderstanding New York No Fault
Understanding New York No Faultmccormick
 

Similar to ERWIN SUAREZ20230323 CLIMBS LIFE.pdf (20)

Health Insurance Proposal Form - HDFC ERGO
Health Insurance Proposal Form - HDFC ERGOHealth Insurance Proposal Form - HDFC ERGO
Health Insurance Proposal Form - HDFC ERGO
 
UB04 EXAMPLE JONES
UB04 EXAMPLE JONESUB04 EXAMPLE JONES
UB04 EXAMPLE JONES
 
KandaMyrvik Workers Compensation
KandaMyrvik Workers CompensationKandaMyrvik Workers Compensation
KandaMyrvik Workers Compensation
 
KandaMyrvik TRICARE
KandaMyrvik TRICAREKandaMyrvik TRICARE
KandaMyrvik TRICARE
 
PRAN- contributory pension for Kerala govt Employees
PRAN- contributory pension for Kerala govt EmployeesPRAN- contributory pension for Kerala govt Employees
PRAN- contributory pension for Kerala govt Employees
 
Pran form
Pran formPran form
Pran form
 
SEC Filing: SV Angel is raising a fifth, $70M fund — its largest to date
SEC Filing: SV Angel is raising a fifth, $70M fund — its largest to dateSEC Filing: SV Angel is raising a fifth, $70M fund — its largest to date
SEC Filing: SV Angel is raising a fifth, $70M fund — its largest to date
 
Revival of Lapsed Policy Forms Fno 680
Revival of Lapsed Policy Forms Fno 680Revival of Lapsed Policy Forms Fno 680
Revival of Lapsed Policy Forms Fno 680
 
KandaMyrvik Medicaid
KandaMyrvik MedicaidKandaMyrvik Medicaid
KandaMyrvik Medicaid
 
Health insurance claim | Health Care Domain
Health insurance claim | Health Care DomainHealth insurance claim | Health Care Domain
Health insurance claim | Health Care Domain
 
Health Suraksha Health Insurance Claim Form - HDFC ERGO
Health Suraksha Health Insurance Claim Form - HDFC ERGOHealth Suraksha Health Insurance Claim Form - HDFC ERGO
Health Suraksha Health Insurance Claim Form - HDFC ERGO
 
Rti pres270911
Rti pres270911Rti pres270911
Rti pres270911
 
QuarterlyV64N2-cover-to-cover
QuarterlyV64N2-cover-to-coverQuarterlyV64N2-cover-to-cover
QuarterlyV64N2-cover-to-cover
 
maternity leave form.docx
maternity leave form.docxmaternity leave form.docx
maternity leave form.docx
 
medical re imbursement application forms,new hospitalsand full government o...
medical re imbursement application forms,new hospitalsand  full government  o...medical re imbursement application forms,new hospitalsand  full government  o...
medical re imbursement application forms,new hospitalsand full government o...
 
Professional liability insurance application for medical director’s
Professional liability insurance application for medical director’sProfessional liability insurance application for medical director’s
Professional liability insurance application for medical director’s
 
Apollo Munich Optima Restore Claim Form
Apollo Munich Optima Restore Claim FormApollo Munich Optima Restore Claim Form
Apollo Munich Optima Restore Claim Form
 
How to Initiate a Life Insurance Claim
How to Initiate a Life Insurance ClaimHow to Initiate a Life Insurance Claim
How to Initiate a Life Insurance Claim
 
Proposal form form300
Proposal form form300Proposal form form300
Proposal form form300
 
Understanding New York No Fault
Understanding New York No FaultUnderstanding New York No Fault
Understanding New York No Fault
 

Recently uploaded

Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17
Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17
Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17Celine George
 
SURVEY I created for uni project research
SURVEY I created for uni project researchSURVEY I created for uni project research
SURVEY I created for uni project researchCaitlinCummins3
 
The basics of sentences session 4pptx.pptx
The basics of sentences session 4pptx.pptxThe basics of sentences session 4pptx.pptx
The basics of sentences session 4pptx.pptxheathfieldcps1
 
The Last Leaf, a short story by O. Henry
The Last Leaf, a short story by O. HenryThe Last Leaf, a short story by O. Henry
The Last Leaf, a short story by O. HenryEugene Lysak
 
II BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING II
II BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING IIII BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING II
II BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING IIagpharmacy11
 
BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...
BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...
BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...Nguyen Thanh Tu Collection
 
Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45
Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45
Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45MysoreMuleSoftMeetup
 
Features of Video Calls in the Discuss Module in Odoo 17
Features of Video Calls in the Discuss Module in Odoo 17Features of Video Calls in the Discuss Module in Odoo 17
Features of Video Calls in the Discuss Module in Odoo 17Celine George
 
How to Manage Closest Location in Odoo 17 Inventory
How to Manage Closest Location in Odoo 17 InventoryHow to Manage Closest Location in Odoo 17 Inventory
How to Manage Closest Location in Odoo 17 InventoryCeline George
 
MichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdfMichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdfmstarkes24
 
An Overview of the Odoo 17 Knowledge App
An Overview of the Odoo 17 Knowledge AppAn Overview of the Odoo 17 Knowledge App
An Overview of the Odoo 17 Knowledge AppCeline George
 
Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...
Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...
Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...Denish Jangid
 
....................Muslim-Law notes.pdf
....................Muslim-Law notes.pdf....................Muslim-Law notes.pdf
....................Muslim-Law notes.pdfVikramadityaRaj
 
An overview of the various scriptures in Hinduism
An overview of the various scriptures in HinduismAn overview of the various scriptures in Hinduism
An overview of the various scriptures in HinduismDabee Kamal
 
How to Analyse Profit of a Sales Order in Odoo 17
How to Analyse Profit of a Sales Order in Odoo 17How to Analyse Profit of a Sales Order in Odoo 17
How to Analyse Profit of a Sales Order in Odoo 17Celine George
 
Software testing for project report .pdf
Software testing for project report .pdfSoftware testing for project report .pdf
Software testing for project report .pdfKamal Acharya
 
MOOD STABLIZERS DRUGS.pptx
MOOD     STABLIZERS           DRUGS.pptxMOOD     STABLIZERS           DRUGS.pptx
MOOD STABLIZERS DRUGS.pptxPoojaSen20
 
Financial Accounting IFRS, 3rd Edition-dikompresi.pdf
Financial Accounting IFRS, 3rd Edition-dikompresi.pdfFinancial Accounting IFRS, 3rd Edition-dikompresi.pdf
Financial Accounting IFRS, 3rd Edition-dikompresi.pdfMinawBelay
 
UChicago CMSC 23320 - The Best Commit Messages of 2024
UChicago CMSC 23320 - The Best Commit Messages of 2024UChicago CMSC 23320 - The Best Commit Messages of 2024
UChicago CMSC 23320 - The Best Commit Messages of 2024Borja Sotomayor
 

Recently uploaded (20)

Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17
Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17
Incoming and Outgoing Shipments in 2 STEPS Using Odoo 17
 
SURVEY I created for uni project research
SURVEY I created for uni project researchSURVEY I created for uni project research
SURVEY I created for uni project research
 
The basics of sentences session 4pptx.pptx
The basics of sentences session 4pptx.pptxThe basics of sentences session 4pptx.pptx
The basics of sentences session 4pptx.pptx
 
The Last Leaf, a short story by O. Henry
The Last Leaf, a short story by O. HenryThe Last Leaf, a short story by O. Henry
The Last Leaf, a short story by O. Henry
 
II BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING II
II BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING IIII BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING II
II BIOSENSOR PRINCIPLE APPLICATIONS AND WORKING II
 
BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...
BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...
BỘ LUYỆN NGHE TIẾNG ANH 8 GLOBAL SUCCESS CẢ NĂM (GỒM 12 UNITS, MỖI UNIT GỒM 3...
 
Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45
Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45
Exploring Gemini AI and Integration with MuleSoft | MuleSoft Mysore Meetup #45
 
Features of Video Calls in the Discuss Module in Odoo 17
Features of Video Calls in the Discuss Module in Odoo 17Features of Video Calls in the Discuss Module in Odoo 17
Features of Video Calls in the Discuss Module in Odoo 17
 
How to Manage Closest Location in Odoo 17 Inventory
How to Manage Closest Location in Odoo 17 InventoryHow to Manage Closest Location in Odoo 17 Inventory
How to Manage Closest Location in Odoo 17 Inventory
 
MichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdfMichaelStarkes_UncutGemsProjectSummary.pdf
MichaelStarkes_UncutGemsProjectSummary.pdf
 
An Overview of the Odoo 17 Knowledge App
An Overview of the Odoo 17 Knowledge AppAn Overview of the Odoo 17 Knowledge App
An Overview of the Odoo 17 Knowledge App
 
Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...
Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...
Basic Civil Engineering notes on Transportation Engineering, Modes of Transpo...
 
....................Muslim-Law notes.pdf
....................Muslim-Law notes.pdf....................Muslim-Law notes.pdf
....................Muslim-Law notes.pdf
 
An overview of the various scriptures in Hinduism
An overview of the various scriptures in HinduismAn overview of the various scriptures in Hinduism
An overview of the various scriptures in Hinduism
 
How to Analyse Profit of a Sales Order in Odoo 17
How to Analyse Profit of a Sales Order in Odoo 17How to Analyse Profit of a Sales Order in Odoo 17
How to Analyse Profit of a Sales Order in Odoo 17
 
Software testing for project report .pdf
Software testing for project report .pdfSoftware testing for project report .pdf
Software testing for project report .pdf
 
MOOD STABLIZERS DRUGS.pptx
MOOD     STABLIZERS           DRUGS.pptxMOOD     STABLIZERS           DRUGS.pptx
MOOD STABLIZERS DRUGS.pptx
 
Financial Accounting IFRS, 3rd Edition-dikompresi.pdf
Financial Accounting IFRS, 3rd Edition-dikompresi.pdfFinancial Accounting IFRS, 3rd Edition-dikompresi.pdf
Financial Accounting IFRS, 3rd Edition-dikompresi.pdf
 
UChicago CMSC 23320 - The Best Commit Messages of 2024
UChicago CMSC 23320 - The Best Commit Messages of 2024UChicago CMSC 23320 - The Best Commit Messages of 2024
UChicago CMSC 23320 - The Best Commit Messages of 2024
 
Mattingly "AI and Prompt Design: LLMs with Text Classification and Open Source"
Mattingly "AI and Prompt Design: LLMs with Text Classification and Open Source"Mattingly "AI and Prompt Design: LLMs with Text Classification and Open Source"
Mattingly "AI and Prompt Design: LLMs with Text Classification and Open Source"
 

ERWIN SUAREZ20230323 CLIMBS LIFE.pdf

  • 1. CtIMBS LIFE AND GENERAL INSURANCE COOPENATIVE CtIMBS Bldg.. Zone 5, National Hi€hway, Butua, 9O00 Cagayan de Oro City, philippines TelephonelFax Nos.: (o8822) 738738; {OsB} 9s61355 Email: head*office@climbs.cooF - *^ rfi INDIVIDUAT APPLICATION FOR GROUP INSURANCE N: IU Application No. Fremiurn Amount sf lnsurance (Cooperative, Assdciofrbfl, Lefidiftg, Frafessia$*ls, Ssci,rnly gusrds. etc.l 7 41001 foop Loan Protecti0n Plan - CIPF Name oi Group Graup Type Group/Employer Name Natura pf WorklEn$loym€ntlSourrc of Fund Other GrpuF Mernbershlp [ 1] Preient Address purro"nunt sii."r. 0 " P" Ri >al .Pos'orq P i q D.rsra(?L Last Nam€ DatP Df Type I tprivare I lceernnenr { ]Retiremenr I isell Fmptowd I lorheri_ HE*IT}I BECLAftATIOII TOBM Please answer each of the foltowing questions in full disclosure/utmost good faith. Check in the box Brovided for details, provide particulars if available {such as existin* clinica} records}. l'. Are you aware of any health disorder or advice from doctor that you are suffering from any:llfless- ----- I lyES t4Nc lf YES, please specify _ Are you in gcod health and entirely lree frorn any mental or physical impairrnent and/or deformlli6l----*..-*- -------- [ ]yf;T7?;6 If YES, please speciry 1. 3. 5. 6, Are you taking medicarion of any kind? tf yES. for what? i/ivrS f trrio Are you taking medication of any kind? tf YES. for what? i/wr* r r*..t Please provide the name/address and the telephone number of yc,ur attending phyrician I DECIARE, that the above arswers are true and correct, and I agree that these shall be the basis of the isruance of lnsurance for me under the Group Policv and that CLIMBS shall ftot be liable {or any claims on account nf illness, iniury or death, the cause of which was known prior to *pproval of my request for insuranre and u/ithheld or concealed in th€ above statenreilts. I hereby authoriz€ any physician, doctors. hospital, clinic, that has any knowledge of rny medical records to disclose when request*d to do so by CtlMBS. I UHDERSTAND that diqualtfication {r$m eoyErago wlll efi;tla me only to refund of premium without interest. signecat -PITQ& .6y9?g) . --. . rhis to r) Narfie & Signature of Authorized Sfficer FON TOAN OFF'CER UsT OilLY Name of Group LoanStatusi )fVew ( ) Renewaj & Signature/Thumb mark of Applicanr Mernber Amount of Loan Granted Date Releas€ Term of Loan {months) Maturity Date Fremium Due Term of lnsurance Coverage Paid (months) Name'and Signatr;re oi Loan Officer Name and Signature of Applicant Menrber ereditor CLIMBS LIFE AFID GENERAL I$ISURANCT CO$PERATIVE tIMBs Bldg., Zane g. {;tioa6} f,t€hwav. EEtua. ,OO0 Cl8ayan d€ Oro Ctty, phiiippines te,eFhone/aat ilos.. i0$8221 7f87l8i loa8i 8561:55 Em&]r head-sili.e€€liHbr.rep CONTiRMATION OT SOVEffIGE CLIMES Life and General lnsurance Cooperative certifien that it hi6 in*ured the follor*ing perron,/s: lnsured Memher Beneficiarylies Expin{ OatE: Amcunt of lnsurance: Pr€mium: Group Policy No.: Effective Sate: ln atcordance wjth the provisions ef the Master Policy, CLIMBS will pay to the lnsured Member or Eeneficiary/ies of the lnsured Member rhe face amaunt of the benefits as found irr the Schedule of Senefits up te the maxiffiufi afiount ifi the Mast€r Policy, promptly upon receipt of satisfactory proof of claims. This certificate will in no way void any s{ the provisions in the Master p*licy" Coop Lrran Protection Pla$ Nrl$744BSl lssue Date Narne and Signature of Authorieed Officer