NBO Support Card Application Form

FOR CITIZENS RESIDING IN NEGROS
Citizens residing in Negros kindly click here instead

SOURCE OF APPLICATION
Do you a Support Card card? *

I am renewing an old card No I do not, I am only just applying for this insurance now Yes I got one and am activating it now
What type card do you have? *
Did your card come free with a product? *

Yes No
How much did you pay for your card? *
Enter amount
YOUR CARD NUMBER. *
NUMBERS ONLY, DO NOT INCLUDE THE "NBO" PORTION
Proof of possession: Take a selfie holding the card *
REFERRAL
Did someone refer you? *

Yes No
If yes who referred you?

INSURANCE OPTIONS
CLICK HERE TO VIEW DETAILS ABOUT INSURANCE LEVELS
Which Level of protection are you applying for?

PAYMENT OPTIONS
Insurance Cost hidden
Insurance Cost
How will you pay *

G-Cash Credit/Debit Card
G-CASH
HOW TO PAY THROUGH G-CASH

Send your payment to 0998-840-1758 (Mariejo Vifree A.).

Note of the Time and Date of transaction to be entered below
Date and time on the receipt *

Month Day Year
Date Hour Minutes AM/PM Option
CREDIT/DEBIT CARD
CREDIT/DEBIT CARD PROCESSING FEE
- ONLINE PROCESSING FEES: P50
PAYPAL HIDDEN
Total

prev next ( X )
PHP Description

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
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:

FOR CITIZENS RESIDING IN NEGROS

SOURCE OF APPLICATION

REFERRAL

INSURANCE OPTIONS

PAYMENT OPTIONS

G-CASH

CREDIT/DEBIT CARD

PERSONAL DETAILS

INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION