NBO Support Card Application Form

CARD SOURCE
Do you already have a card? *

Yes I got one and am activating it now No not yet I am just ordering now I have been pre-approved to avail of FREE accident insurance
Which card do you have *
Did your card come free with a product? *

Yes No
How much did you pay for your card? *
Enter amount
Who did you get your card or product from? *
Enter Name of Retailer/Agent
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
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
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

DELIVERY FEE TO BE PAID FOR BY CUSTOMER
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)
Conforme:

I agree to shoulder delivery costs

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:

CARD SOURCE

REFERRAL

INSURANCE OPTIONS

PAYMENT OPTIONS

DELIVERY OPTIONS

PERSONAL DETAILS

INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION