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Products and Services » Group Proposal Request 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:CVL@mx.insular.com.ph
worksite-sup2@express.insular.com.ph
guerglg@express.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:
Give me a Printable Version (Send through Fax)
Back to Employee Benefit Programs Page
 

Employee Benefit Program

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