FPG Insurance

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Application Form

1 Property Details & Coverage

2 Personal Details

3 Submit

4 Success

Location to be Insured

BLOCK/LOT/PHASE NO. *

STREET *

VILLAGE/SUBDIVISION *

BARANGAY *

CITY *

PROVINCE *

ZIP *

Interest to the Property being Insured

OWNER-RESIDENT

OWNER NON-RESIDENT

TENANT

Boundaries (description of the surroundings of the property to be insured)

FRONT *

LEFT *

RIGHT *

BACK *

IS THE PROPERTY MORTGAGED?

YES

IF YES, PLEASE SPECIFY

Coverage

ITEMS TO BE INSURED *

BUILDING (PHP) *

CONTENTS (PHP) *

LEASEHOLD & IMPROVEMENTS (PHP) *

INCEPTION *

EXPIRY *

Personal Accident Insurance

FAMILY PERSONAL ACCIDENT INSURANCE

LAST NAME	FIRST NAME	MIDDLE NAME	BIRTHDAY

HOUSEHOLD PERSONAL ACCIDENT INSURANCE

LAST NAME	FIRST NAME	MIDDLE NAME	BIRTHDAY

NOTE: In case of claim, any proof of employment such as, but not limited to, copy of contract signed before the accident, payslip, SSS remittance, etc. must be provided.