Vul Application

1 x 1 ID Photo 1 x 1 ID Photo
Department of Finance
INSURANCE COMMISSION
APPLICATION FOR INSURANCE AGENT'S LICENSE

(Under Chapter IV, Title I of the Insurance Code)
To the Insurance Commissioner:
The undersigned hereby applies for a license under the provisions of Chapter IV, Title I of the
Insurance Code, to act as insurance/general agent of AIA Philippines Life and General Insurance
Company, Inc. (formerly Philippine American Life and General Insurance Company) in respect
of the kind of insurance indicated herein:
NON-LIFE LIFE VARIABLE LIFE ACCIDENT AND HEALTH
Others (please specify) ________________________
and for that purpose submits the following statements and information required herein.
___________N/A___________
(Agency Name if any)
1. Name of applicant: PANGAN, LOIDA MANALANG

(Surname) (First Name) (Middle Name)
2. Agent Type: Ordinary Agent ( ) General Agent (___)

3. Home Address: 224 DEL POSO ST. TANGOS, BALIUAG, BULACAN, 3006
Business address: N/A
T I N: 103625649000 E-mail Address: loi_pangan@yahoo.com
4. Birth a) Date: 1965-11-06 b) Place: SAN SIMON, PAMPANGA
5. Citizenship: Filipino Sex: F Civil Status: SINGLE
6. If married, a) Maiden Name: __________N/A_________

b) Husband's or Wife's Name: _________N/A__________
7. If naturalized citizen of the Philippines, give date and place of naturalization and attach photocopy
of certificate of naturalization._________N/A_________.
FOR IC USE ONLY

Verified by: ____________ Date: ____________ Processed by: ____________ Date:
____________
Approved by: ____________ Date: ____________
License Fee: __________ OR No. __________ Date: __________ CA No. __________
REMARKS:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Application for Insurance Agent's License
Insurance Commission
8. If applicant is a foreigner, give serial number, date and place of issue of alien certificate of
registration (ACR) and the immigrant certificate of residence (ICR) for the current year and attach
photocopy of each thereof __________N/A_________.
9. If applicant is a partnership, association or corporation:

1. Attach a certified true copy of the certificate of registration, articles of partnership,
association or incorporation and by-laws:
2. State percentage of Filipino participation in the partnership, association or corporation:

__________N/A__________
10. Any license previously granted to act as insurance/general agent in this country? State name of
insurance company represented.N/A
11. Have you filed your income tax return for the preceding year? NO If not, give reason NO MORE
INCOME BECAUSE I RETIRED ON DECEMBER 31, 2020.
12. In the blanks below, state your last (2) employers.
Name of Employer Position Inclusive Dates

K SERVICO TRADE, INC. Middle-Level Management 1991 May - 2020 December
N/A N/A N/A
13. Are you an official or an employee of an insurance company or broker? If yes, give the position
held: NO.
14. Are you a government employee? NO ; If yes, attach the necessary clearance/permission from the
Head of the Department or Agency in accordance with Section 18, of Memorandum Circular #15,
series of 1999 of the Civil Service Commission.
Executed this ____ day of ___________20____, at ______________________________

___________________, Philippines.
LOIDA MANALANG PANGAN

Applicant
Note: This form may be revised without prior notice. 2

AFFIDAVIT OF VERIFICATION
Republic of the Philippines)

Province/City of _________) S.S.
I, LOIDA MANALANG PANGAN, being duly sworn, depose and say that I am the person named in and
who signed the foregoing application; that I know the contents thereof and the statements made and
answers to question therein are true.
_________________________
Affiant
TIN: 103625649000
SSS No.: 0387081195
SUBSCRIBED AND SWORN TO before me this _______ day of _________________________

20_____, Affiant/s exhibited to me his/her _____________________ issued on __________
_____________________20______, at ______________________________________.
Notary Public
Doc. No. ______

Page No. ______
Book No. ______
Series of No. ______
APPROVED AND COUNTERSIGNED for AIA Philippines Life and General Insurance Company,
Inc.
For the solicitation or procurement of application for life/variable/non-life insurance
Authorized Representative of the Company

CERTIFICATE OF WAIVER
WE HEREBY CERTIFY:
That we know the applicant LOIDA MANALANG PANGAN, that a thorough investigation has
been made into his/her character, conduct and fitness; he/she is of good moral character and worthy of a
Certificate of Authority, and that he/she has had experience in each of the kinds of insurance he/she
proposes to write or solicit under the Certificate of Authority applied for.
That we have communicated with the former and present employees of the applicant and the
replied have been satisfactory
That to the best of our knowledge, information and belief, all statements and answer contained in
the application have been in the handwriting of the applicant with respect to the questions applicable to
him/her.
If and when the agency is terminated, written notice thereof will be given forthwith to the
Insurance Commission together with the reason therefore.
In consideration of the Certificate of Authority to be issued to the above-mentioned applicant,

under the provision of Section 299 of the Insurance Code, we hereby waive, on behalf of --
AIA Philippines Life and General Insurance Company, Inc.

(Company Name)
the right to appeal to the Secretary of Finance in case of revocation by the Insurance Commissioner of
the certificate to be issued in favor of the above-mentioned applicant and agree to cancel at once the
contract of agency between said applicant and the company upon receipt of the notice of revocation.
Executed in __________________ on __________________________
TIN 000-803-117-000
BY _____________________________________
Authorized Representative of the Company
N.B. No person, partnership, association or corporation required by Law to file an income tax return shall
be issued a license to engage in any trade, business or occupation o practice a profession unless he
shall have presented to the officer issuing such license or permit proof that he has filed his income tax
return during the preceding year and that income taxes due have been paid thereon. For the purpose of
this Act, a copy of such income tax return on which is shown a certification or statement by the Collector
of Internal Revenue or his duty authorized representative that the aforesaid income tax return, and the
corresponding receipts showing payment of all income taxes due thereon, shall be sufficient proof.
Any person, partnership, association or corporation who obtains a license mentioned in the preceding
paragraph without presenting the aforementioned certification of the Collector of Internal Revenue or his
duly authorized representative, under the pretext that he or it is not required by law to file an income tax
return when in truth he or it is so required, or under any other misrepresentation, shall be liable to fine of
not more than Five Hundred Pesos, or imprisonment of not more than one year or both, in the discretion
of the Court. In case of partnership, association, the manager or the equivalent officer thereof shall be
held responsible and in addition, the license shall be revoked. (Section 1, Republic Act No. 1568).

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APPLICATION FOR INSURANCE AGENT'S LICENSE

To the Insurance Commissioner:

NON-LIFE LIFE VARIABLE LIFE ACCIDENT AND HEALTH

Others (please specify) ________________________

1. Name of applicant: PANGAN, LOIDA MANALANG

2. Agent Type: Ordinary Agent ( ) General Agent (___)

4. Birth a) Date: 1965-11-06 b) Place: SAN SIMON, PAMPANGA

5. Citizenship: Filipino Sex: F Civil Status: SINGLE

6. If married, a) Maiden Name: __________N/A_________

FOR IC USE ONLY

9. If applicant is a partnership, association or corporation:

2. State percentage of Filipino participation in the partnership, association or corporation:

12. In the blanks below, state your last (2) employers.

Name of Employer Position Inclusive Dates

Executed this ____ day of ___________20____, at ______________________________

LOIDA MANALANG PANGAN

Note: This form may be revised without prior notice. 2

Republic of the Philippines)

SSS No.: 0387081195

SUBSCRIBED AND SWORN TO before me this _______ day of _________________________

Doc. No. ______

Authorized Representative of the Company

Note: This form may be revised without prior notice. 3

In consideration of the Certificate of Authority to be issued to the above-mentioned applicant,

AIA Philippines Life and General Insurance Company, Inc.

Executed in __________________ on __________________________

Note: This form may be revised without prior notice. 4

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6. If married, a) Maiden Name: __N/A_

Executed this day of _20, at ________________________

SUBSCRIBED AND SWORN TO before me this _ day of ___________________

Executed in on ________