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$744BSl
lssue Date
Narne and Signature of Authorieed Officer
![CtIMBS LIFE AND GENERAL INSURANCE COOPENATIVE
CtIMBS Bldg.. Zone 5, National Hi€hway, Butua, 9O00 Cagayan de Oro City, philippines
TelephonelFax Nos.: (o8822) 738738; {OsB} 9s61355 Email: head*office@climbs.cooF
- *^ rfi
INDIVIDUAT APPLICATION FOR GROUP INSURANCE N: IU
Application No.
Fremiurn
Amount sf lnsurance
(Cooperative, Assdciofrbfl, Lefidiftg, Frafessia$*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](https://image.slidesharecdn.com/erwinsuarez20230323climbslife-231108070412-eeeaf311/85/ERWIN-SUAREZ20230323-CLIMBS-LIFE-pdf-1-320.jpg)
