NBO Support Card Application Form

CLICK HERE TO VIEW LIST OF BENEFITS
CARD SOURCE
Did you already buy a card? *

Yes I got one and am activating it now No not yet I am just ordering now
YOUR CARD NUMBER. *
NUMBERS ONLY, DO NOT INCLUDE THE "NBO" PORTION
How much did you pay for this card? *

380 440 500 560
REFERRAL
Did someone refer you? *

Yes No
Who referred you?

INSURANCE OPTIONS
Would you like to upgrade your insurance? *

Yes No

COVERAGE	INCLUDED/FREE	UPGRADE (Add P60)
Accidental Medical Reimbursement	P10,000	P20,000
Unprovoked Assault	P100,000	P200,000
Accidental Death	P100,000	P200,000
Unprovoked Murder	P100,000	P200,000
Permanent total disablement	P100,000	P200,000
Burial Expense	P10,000	P20,000

PAYMENT OPTIONS
Insurance Cost hidden
Amount to pay hidden
Support Card Cost
How will you pay *

7-11 Outlets Credit/Debit Card
HOW TO PAY THROUGH 7-11 OUTLETS

Before you continue to register, payment must 1st be made at a 7-11 outlet. The steps for payment is as follows:
1. Go to a 7-Eleven branch in your area, and look for the CLiQQ kiosk.
2. Choose “e-money,” and click Coins.ph.
3. Ensure that the number that you place is the NATIONAL BICYCLE ORGANIZATION #: 0947-747-4635.
4. Provide the payment slip to the cashier to pay.
5. Take note of the 12 digit Reference Number located in the Receipt.
Once you have finished this, come back to this form to finalize your registration
Enter the 12 Digit reference number on the receipt *
Date on the receipt *

Month Day Year
Date
CREDIT/DEBIT CARD PROCESSING FEE
- ONLINE PROCESSING FEES: P50
PAYPAL HIDDEN
Total

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PHP Description

DELIVERY OPTIONS
How would you like to receive your card?

I will pick card up from NBO Headquarters I want it delivered by Grab or Lalamove (Metro Manila & Surrounding areas) I want it delivered by LBC or JRS express (Outside Metro Manila)

PERSONAL DETAILS
Name *

First Name Middle Name Last Name
Gender

Male Female
Civil Status *

Single Married Other
Mobile # *
Email *
example@example.com

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date *

Month Day Year
Date

INSURANCE INFORMATION
Name of employer *
Business Address *
Business Telephone No(s) *
Profession/Occupation *
Nature of Work *
Annual income in Pesos *
Beneficiary (ies)/Relationship *
Do you have any physical defect or infirmity of any kind or have you ever had diabetes, tuberculosis, varicose veins, disease of the heart or brain, amputation, impairment of hearing of sight or any nervousaffection? *

No Yes
Please give details *
During the last 5 years, have you been hospitalized or consulted a physician for any reason? *

No Yes
Please give details *
With what company (ies) and for what amounts are you presently insured? *

No Yes
Please give details *
Have you ever claimed or received compensation under any accident or sickness policy? *

No Yes
Please give details *
I hereby certify that all information given in this application are true and correct. I understand that non- disclosure and/or falsification of information herein required shall be grounds for the disapproval of my application, immediate termination of the insurance coverage and/or legal action against me. *

Conforme, I agree
Sign using your mouse or finger if you are using a smartphone/tablet *

Clear
NOTE: Under Republic Act 9160 (Anti-Money Laundering Act) as amended by Republic Act 9194 and pertinent regulations, all insurance companies are required to satisfactorily establish the identities of all its customers. Hence, Standard Insurance Co., Inc. reserves the right not to accept and process any application for insurance if the customer fails to provide sufficient evidence to establish his identity

EMERGENCY CONTACT INFORMATION
Name *

First Name Middle Name Last Name
Mobile #
Relationship to you

Spouse Parent Child Friend Relative
Should be Empty:

CARD SOURCE

REFERRAL

WHO DO YOU WANT TO SUPPORT?

INSURANCE OPTIONS

PAYMENT OPTIONS

DELIVERY OPTIONS

PERSONAL DETAILS

INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION