Department of Finance INSURANCE COMMISSION, ‘APPLICATION FOR INSURANCE AGENT'S LICENSE (Under chapter, Tite ofthe insurance code) To the Insurance Commissioner: ie, undersigned hereby applies for license under the provisions of Chapter, Tile of the Insurance Code, to act Fe, taurance/keneral agent of the THE INSULAR LIFE ASSURANCE CO.,LIDin respect ofthe kind oftneurance ndtsed OC nowure G ure © varusteure ——O) accioewr ano eau Bhorecsieey) {and for that purpose submits the following statements and information required herein, NA, (Agency name ifany) 1. Name of Applicant: PALMARES. ALFREDO CLEMENT CANTO, (Surname} (First Name) (Midale Narre) 2. Agent Type: Ordinary Agent(~) General Agent( ) 3, Home Address: __184 MCARTHUR HIGHWAY, RICA VILLAGE, CUBAY JARO, ILOILO CITY, ILOILO 5000 Business Address: _ 184 MCARTHUR HIGHWAY, RICA VILLAGE, CUBAY JARO, ILOILO CITY, ILOILO 5000 TIN: 260-20-0462 Esmall Address: [email protected] Mobile Number: 639173288899 4, Birth Date: o1/22i974 rth Place: ILOILO CITY 5. Citizenship: FILIPINO Gender: MALE Marital Status: MARRIED 6 IfMarried a) Maiden Name: b) Spouse Name: MA. LEONOR JAVELLANA PALMARES 7. If naturalized citizen of the Philippines, give date and place of naturalization and attach photacopy of certificate of naturalization N/A. FORICUSE ONLY Verified by: Date: Processed by: Date: ‘Approved by: Date: Ucense Fee: ORNo.: Date CANO: REMARKS:'fapplicant isa partnership, association or corporation: — a) Attach a certified true copy of the certificate of registration, articles of partnership, association or incorporation and by-laws, ») ‘State percentage of Filipino participation in the partnership, association or corporation: N/A eile intr? State name of insurance company 10. Any license previously granted to act as insurance/general agent in this cour represented: NO. If not, give reason: NONE 11. Have you filed your income tax return for the preceding year? YES 12. Inthe blanks below, state your last (2) employers: Name of Employer L Where GLOBAL, ILOILO CITY INTERNATIONAL Reason For Leaving In What Capacity —| NIA ENTERPRISES ‘Are you an official or an employee of an insurance company or broker? If yes, give the position held: NO. NO ___ If yes, attach the necessary clearance/permission from the Head of the 14. Are you a government employee? Department or Agency in accordance with Section 18, of Memorandum Circular No. 15, series of 1999 of the Civil Service Commission. ‘Executed this 8TH this day of APRIL 20_22 ,at ILOILO CITY » Philippines.WE HEREBY CERTIFY: PALMARES, ALFREDO CLEMENT _ , that a thorough investigation has been That we know the applicant i CANTO ‘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 replies have been satisfactory. That to the best of our knowledge, information and belief, all statements and answers contained in the application have been in the handwriting of the applicant 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 thereof. 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 - ‘THE INSULAR LIFE ASSURANCE CO., LTD the right to appeal to the Secretary of Finance in case of revocation of 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, 04/08/2022 ‘THE INSULAR LIFE ASSURANCE CO., LTD “TIN 320-000-464-124 a Authorized Representative of the Company Executed in MUNTINLUPA ‘on 'N.B. No person, partnership, association or corporation required by Law to file an income tax return shall be issued : license to engage in any trade, business or corporation or practice a profession unless he shall have presented to {ssuing such license or permit proof that he has filed his income tax return during the preceding year and that incor due have been paid thereon. peta retions Ls AS a coe of sch nga tx reno SEN aa by the collector of Internal Revenue or his duly authorized representative that the afor s r corona Sa iRepublic of the Philippines) Province/City of )ss. ‘ a | PALMARES, ALFREDO CLEMENT being duly sworn, depose and say that | am the person named in an! CANTO ho signed the foregoing application; that know the contents thereof and the statements made and answers to question therein are true, Affiant TIN 260-20-0462 S85 No. (07-2043676-3 SUBSCRIBED AND SWORN TO before me this RAYS day of Swe 2022 _aifiant/s exhibited to me his/her__ POL td COOoSAY issuedon OLN Lo ig 20 vat Woo ty 5 AL = 5 Pu ms s LIC UNTIL INE $0/2022 CITY &FROVINCE OF ILOILO PTR NG. 7700794 /LOILOCITY/ JANUARY 6 2022 SSO MILOWG MYT ARUARY 5: 2022 Ig NO. 00189911! Aue Doc. No. AV PageNo. ~_ 2m Book No. L Series of 2022. APPROVED AND COUNTERSIGNED for the THEINSULAR LIFE ASSURANCE CO.,LTD for __ Procurement of application for life/non-life nce.