10.

Do you have a personal history of any of the ff: (if YES, encircle the number)
1. Arthritis/Rheumatism 20. Hemmoroids/Anal fistulae
APPLICATION FORM 2. Asthma/Tuberculosis/Pulmonary hypertension
3. Blood dyscrasia /Leukemia/Anemia
21. High Cholesterol/Dyslipidemia
22. High blood pressure/Hypertension
4. Bone disease/Osteoporosis 23. Injury from accident or assault
NAME ___________________________________________________________________________ 5. Cancer/Malignant tumor 24. Kidney or urological disease
Last Name First Name Middle Name 6. Cataract/Glaucoma 25. Liver disease/Hepatitis/Cirrhosis
7. Central nervous system disease 26. Meningitis/Encephalitis
ADDRESS (Mailing Address) 8. Cerebral palsy 27. Myoma/Ovarian Cyst/Breast mass/
9. Congenital heart disease/MVP Endometriosis
_________________________________________________________________________________ 10. Congenital illness/Down’s syndrome/Autism 28. Organ transplant
Number Street Subdivision/Village Barangay 11. COPD/Emphysema/Chronic Bronchitis 29. Physical deformity or disability/Spinal
12. Craniotomy/VP shunt stenosis
_________________________________________________________________________________ 13. Cyst/Tumor of internal organ 30. Prostate Problem
Municipality/City Province Zip Code 14. Diabetes Mellitus 31. Psychiatric disorder/Psychosis
15. Epilepsy 32. Rheumatic fever/Rheumatic heart disease
PHONE NUMBER/S 16. Eye, nose or throat tumor/Sinus requiring surgery 33. Sexually transmitted disease/AIDS
Mobile Number (_______)(________________) 17. Gall bladder or biliary stones 34. Stroke/Cerebrovascular accident
Home/Office Phone Number (_______)(________________) (If provincial, include Area Code) 18. Goiter/Hyperthyroidism 35. Ulcer/Colitis/Diverticulosis
Would you like to receive your policy and notifications in e-format thru email? □Y □N 19. Heart attack/Heart disease

36. Urinary tract stone/Chronic renal failure
37. Other/s________________
(E-mail Address)________________________________________________

□ Single □ Married □ Separated □ Widowed □ Male □ Female

DATA PRIVACY I acknowledge that Malayan Insurance Company, Inc. (Malayan) may collect, use, process and share my personal information to
CIVIL STATUS GENDER its employees, duly authorized representatives, other insurers, reinsurers, adjusters, investigators, and other third party providers for purposes such
as underwriting, administration, claims adjudication and management, investment, data analytics, statistical analysis, risk analysis/ assessment/
management, financial and tax monitoring/review/reporting, protection against fraud, errors, or misrepresentations, profiling, research, due
diligence, company evaluation, studies/customer satisfaction surveys, and compliance with legal, regulatory or contractual requirements. Further, I
DATE OF BIRTH mm_____/dd_____/yy________ PLACE OF BIRTH: _______________________ agree that Malayan may notify and offer me any of its products and services that may be useful to me. In furtherance of these purposes, my personal
information, unless prohibited, may be processed outside the Philippines and be subject to different data protection
standards.
TYPE OF EMPLOYMENT: AUTHORITY TO VERIFY INFORMATION I also authorize Malayan to verify and investigate the information given by me, including submitted
□ Employed Tax Identification Number (TIN) ____________________
documents from whatever source it may consider appropriate.
RIGHTS OF THE DATA SUBJECT I acknowledge that I have the right to access the given information and I undertake to correct, rectify or
□ Private SSS Number: _________________________________
supplement the same should any information be found to be inaccurate or incomplete. I shall notify Malayan in writing of any changes in the

□
information given above.
UNDERTAKING I hereby warrant that all personal information given by me are true, correct, updated to the best of my knowledge, and freely and
Government & Government-related GSIS Number: _________________________________
□
voluntarily given to Malayan. I agree and consent that the above information are being collected, used, processed and recorded for purposes of
OFW securing insurance protection or any other business transaction(s) with Malayan and for other purpose as indicated herein.
If purchasing, transacting and/or acting in behalf of other person(s), I hereby warrant that I have been duly authorized to perform such acts and
Position:____________________________ permitted to give their information to Malayan. I hereby bind myself to advise all other persons in whose behalf I have acted, transacted with and/
□ Professional
or purchased any product or services from
Malayan of all the terms and conditions herein. I will hold Malayan, directors, officers, employees, agents, successors and assigns free and harmless
□ Business (Self-employed)
from any liability that may arise as a result of the authorization given above.

□
By signing this form, I hereby certify that I have read and understood the foregoing and this consent remains valid and binding unless I submit a
written notice to Malayan revoking or altering the same.
Others AUTHORITY TO DISCLOSE By ticking the box, I hereby authorize Malayan to grant the members of the Yuchengco Group of Companies
INDUSTRY _________________________________ (YGC), their and Malayan’s affiliates, subsidiaries, contractors, partners, agents and representatives, intermediaries, industry associations,
and other third parties access to my personal information, including this form, for purposes of marketing, sales or promotional information
campaigns, and provision of any products, services, or offers through mail/email/SMS/telephone, or any type of electronic facility.
BENEFICIARY_____________________________ RELATIONSHIP ____________________________
IN WITNESS HEREOF, I have signed this Application on ______________ in __________________.
NAME OF EMPLOYER (if any) _________________________________________________________
Signature: Signature:
GROUP AFFILIATION OF EMPLOYER (if any) _____________________________________________ (Client’s signature over Printed Name) (Date Signed) (Broker, Agent or other Authorized Representative of Client) (Date Signed)
NAME OF BUSINESS (if any) __________________________________________________________
-----------------------------------------------------------------------------------------------------------------------------------------
NET INCOME: _____________________________________________
*To be filled up by Company Representative:

Please answer all of the following questions with Yes or No.
Verified by: ______________________________________ Date Received: ___________________
1. Have you been a patient in a hospital, clinic or sanitarium in the past 5 years? _________
(Name & Signature of Malayan Insurance frontliner)
If YES, please give details. _______________________________________________________
2. Have you ever availed of any medical or surgical treatment?_________
If YES, please give details.________________________________________________________ DISCLAIMER: This brochure is intended to be a general summary. Malayan Insurance Co.,
3. Have you ever been advised to have any diagnostic test, hospitalization, or surgery which was not Inc. reserves the right to modify terms, coverage and limits or decline coverage
done or completed?__________ as it deems appropriate. Submission of the filled-out application form does not
If YES, please give details._________________________________________________________ constitute a commitment to cover and is not a guarantee of acceptance by the
4. Have you applied for or received payment for sickness/injury?__________ Company.
If YES, please give details._________________________________________________________
5. Have you been rejected for insurance/health care plans or offered insurance at higher premiums?
__________
If YES, please give details._________________________________________________________
6. Do you take alcohol, cigarettes, tobacco or any habit-forming drug?_____________
If YES, please give details._________________________________________________________
7. Have you experienced any abrupt change in body weight recently?___________
If YES, please give details. ________________________________________________________
8. Are you presently taking any medication? _________
If YES, please give details. ________________________________________________________
9. (For WOMEN only)
Date of last delivery:_______________________
Are you pregnant?__________ If YES, how many mos.? _________
Abortion, miscarriage, abnormal labor/pregnancy?__________ Yuchengco Tower I, 500 Quintin Paredes St., Binondo, Manila 1006
If YES, please give details._______________________ Tel. No. : (632) 8242-8888 / 8628-8600 • Fax No. : (632) 8242-2222
Name & address of personal physician: _______________________________________________ Website: http://www.malayan.com • E-Mail: [email protected]
_______________________________________________________________________________ AVIATION • ENGINEERING • FIRE • MARINE • MISC. CASUALTY • MOTORCAR • PERSONAL ACCIDENT • SURETY
Date of last consultation:________________
PA-A139-0321-0
Treatment given/medication prescribed:_______________________

Insure to be Sure. Insure to be Sure.