WFMA Inc. - Life and Health Declaration

Life and Health Application Form

Client Information
Agent Code:

First Name:
Last Name:
Middle Name:

Agent Bday:
Civil Status:

Gender: Male
Female

Height:
Weight:

Spouse Name:
Spouse Bday:

Beneficiary
Beneficiary 1:
Bday:

Beneficiary 2:
Bday:

Beneficiary 3:
Bday:

Application Info.
Application Number

Plan:

Currency:

Amount of Insurance

Premium:

Mode of Payment

Term:

SC1:

SC2:

Business Date:

Branch:

MAF #:

Status:

Remarks: