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    I. Information about the Property to be Insured

    All items with asterisk* are mandatory


    1. Is the property to be insured located inside the Public Market? *

    Note: If your answer is YES, do not proceed with the application


    2. Is the property used for business/income generating/commercial purposes? *

    Note: If your answer is NO, do not proceed with the application


    3. Is the property to be insured more than 50 meters (100 steps away) from a creek or any body of water? *

    Note: If your answer is NO, do not proceed with the application


    4. Is the property to be insured made of concrete walls and roofing is made of iron/steel/concrete? *

    Note: If your answer is NO, do not proceed with the application


    5. Number of storeys/floors of building: *


    6. Business Name (ex. Joy Sari-Sari Store) *


    7. Starting Date of Operations *


    8. Type of Business *


    9. Complete Address of Property *

    (House/Bldg. Number, Street Name, Barangay, Municipality/City, Province, Zip Code)

    II. Enrollee’s Information

    All items with asterisk* are mandatory


    Complete Name (Last Name, First Name, Middle Initial) *


    Status *

    Note: If your answer is not OTHER, put N/A


    Date of Birth *


    Gender *


    Current Address *

    (House/Bldg Number, Street Name, Barangay, City/Municipality, Province, Zip Code)


    Mobile Number *


    How are you (the Enrollee) connected to the Property to be Insured? *

    Note: If your answer is not OTHER, put N/A

    III-1. Name of those who will get Personal Accident Coverage (available only for enrollees 65 y/o and below

    All items with asterisk* are mandatory


    Insured 1 (Person to be insured for Personal Accident) *


    Insured 1 - Complete Name *

    (Last Name, First Name, Middle Initial)


    Insured 1 - Date of Birth *


    Insured 1 - Gender *


    Beneficiary's Name *

    (Last Name, First Name, Middle Initial)

    Beneficiary's Date of Birth *


    Beneficiary's Relationship to Insured 1 *

    III-2. Name of those who will get Personal Accident Coverage (available only for enrollees 65 y/o and below)

    All items with asterisk* are mandatory


    Insured 2 - Person to be insured for Personal Accident (Optional)


    Insured 2 - Complete Name

    (Last Name, First Name, Middle Initial)


    Insured 2 - Date of Birth


    Insured 2 - Gender


    Beneficiary's Name

    (Last Name, First Name, Middle Initial)


    Beneficiary's Date of Birth


    Beneficiary's Relationship to Insured 2

    IV. Applicant's Declaration




    Date of Application *


    Applicant’s Declaration (partner can modify according to their own T&Cs, except for the items in red. If these will be reworded, it should still express the same intent -- consent to receive data from AXA, to give info to partners i.e. AXA ) *


    I understand that I can only be covered under one Property microinsurance policy. Should I have enrolled for more than one, I agree to have premiums of excess policies refunded and no claims will be payable under any policy in excess of one.


    I want to receive transaction notifications, be regularly updated by Packworks and its affiliate companies of their products and services, and thus understand fully that my foregoing information will accordingly be shared.


    I have been informed that I have the option not to give the above information, in which case I understand that my transaction will not be processed. I have also been informed that I can make corrections to any inaccurate or deficient information and that I have an option to withdraw my consent prior to the processing of my transaction by emailing Packworks.


    I hereby certify that the foregoing information are freely and voluntarily given and are true and correct to the best of my knowledge. Further, I hereby authorize Packworks to disclose to AXA Philippines my above information to aid in any and all investigations that may be initiated on account of, or in relation to any concerns that may arise out of this transaction.


    Thank you!

    Your application has been received and our team is excited to learn more about you.

    We will be reaching out soon.

    Continue

    Thank you!

    Your application has been received and our team is excited to learn more about you.

    We will be reaching out soon.

    Continue