Application for Agent Accreditation

Personal Information

Last Name

First Name

Middle Name

Suffix

Birthdate

Birth Place

Citizenship

Gender

Civil Status

Email Address

Telephone No.

Mobile No.

Tax Identification Number

Current Address

Street Address

Zip Code

Permanent Address

Same as current address

Educational Background

Vocational

College Graduate

Post Graduate

Work Experiences

Without Work Experience

Job Title

Company Name

Year

Selling Experiences

Type of Products Sold

Please specify:

Product and Sales Orientation

No Orientation Attended

Venue

Conducted By

Date Attended

Affiliations

Have you been an agent of any HMO, Life, Non-life, Pre-need Company before?

Yes No

Has there been any case civil, or criminal filed or pending against you?

Yes No

Have you ever been discharged or terminated from employment?

Yes No

Select Agent Affiliation

Select Agent Level

Specify UM/USM

Specify DSM/GA HEAD/GSM

Requirements for Accreditation Only .jpg, .png, .pdf, .jpeg are allowed

Requirements for Activation Only .jpg, .png, .pdf, .jpeg are allowed

I hereby declare that the above information are true and correct to the best of knowledge and ability and that I shall conduct myself in accordance with all the Rules and Regulations and Company Policies of Insular Health Care, at all times.

I have read and accept the Privacy Policy of InLife Health Care.