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Group Proposal Form

GENERAL INFORMATION :
Date of Request :
Name of Company :
Address :
Telephone No. :
Fax No.:
Nature of Business :
Areas of Operation :
Contact Person :
E-Mail:

EMPLOYEE INFORMATION :

Total number of Employees :

Percentage of Office-Based Employees (administrative/clerical) :

Percentage of Field-Based / Manufacturing Employees :

Are all employees hired on a full time regular basis?

Yes No

If no, how many are on probationary status? :

contractuals?

Employee Census :

Fax the following info to 8173621

Or email:CVLucas@insular.com.ph
rpfrancisco@insular.com.ph
ggenriquez@insular.com.ph

Name/Employee Number

Birth Date

Hire Date

Position/Class

Salary

Claims Experience in the Last 3 Years (if any) :

REQUESTED PLAN :

Group Term Life Insurance
      Riders: Accidental Death & Disability            Total & Permanent Disability
                  Comprehensive Group Accident          Burial
                  Accidental Medical Reimbursement
Comprehensive Group Accident Plan
Group Hospitalization
Comprehensive Group Plan (Retirement)
Credit Group Life / Mortgage Redemption Insurance

SCHEDULE OF BENEFITS :

Class / Position	Amount of Insurance

Who will shoulder the cost of the plan?
Employer
Employees
Shared

Present carrier and renewal date [when applicable]
Group Term:
Hospitalization:
Others:

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