MUNTINLUPA CARE CARD - Application Form (Part 1) CONTROL NO.

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Direction: Please fill out all information completely. Shade the appropriate circle. To be provided by authorized personnel.
Direksiyon: Pakipunan ang lahat ng impormasyon sa ibaba. Itiman ang angkop na bilog. DATE OF APPLICATION: / /
M M D D Y Y Y Y
APPLICATION TYPE: Dependent (7 to 17 years old) Primary (18 to 59 years old) Senior Citizen (60 & above)

A. IDENTIFICATION / PAGKAKAKILANLAN //appformonline v1.0

A.1 SALUTATION / PUGAY Mr. Mrs. Miss Others, specify: _________ A.5 DATE OF BIRTH / PETSA NG KAPANGANAKAN
A.2 LAST NAME / / /
APELYIDO M M D D Y Y Y Y
A.3 FIRST NAME /
A.6 AGE TO DATE / EDAD SA NGAYON
PANGALAN
A.4 MIDDLE NAME /
GITNANG PANGALAN

B. COMELEC REGISTERED ADDRESS / NAKAREHISTRONG TIRAHAN SA COMELEC

B.1 HOUSE/LOT/BLOCK/
BUILDING NO. & NAME
B.2 STREET / ROAD /
AVENUE

B.3 SUBDIVISION / PUROK

B.4 BARANGAY

B.5 CITY/MUNICIPALITY M U N T I N L U P A B.6 ZIPCODE

*** For Authorized Personnel Used Only: (Please do not write below this page. / Pakiusap huwag sulatan ang mga nasa ibaba. ) ***
Verified By: / / : AM / PM
Signature over printed name M M D D Y Y Y Y H H M M

If not verified, write reason here:

MUNTINLUPA CARE CARD

Claim Stub

MCC #: -

Date of / /
Application: M M D D Y Y Y Y

Last Name:

First Name:

Middle Name:

Date of Birth:
M M D D Y Y Y Y
* Certifying I received the card. Pagpapatunay na natanggap ko na ang kard.
Signature:
Released / /
Date: M M D D Y Y Y Y
MUNTINLUPA CARE CARD - Application Form (Part 2) CONTROL NO.: -

Direction: Please fill out all information completely. If not applicable, write 'NA'. Shade the To be provided by authorized personnel.
appropriate circle. (Direksiyon: Pakipunan ang lahat ng impormasyon sa ibaba. Kung hindi akma, DATE OF
isulatang 'NA'. Itiman ang angkop na bilog.) APPLICATION: / /
M M D D Y Y Y Y

C. PERSONAL DETAILS / PERSONAL NA DETALYE

C.1 GENDER / KASARIAN Male Female C.2 HEIGHT / TAAS FT INCHES C.3 WEIGHT / TIMBANG KILOS

C.4 CIVIL STATUS Single Married Widow/er Legally Separated Annulled

C.5 PLACE OF BIRTH /
LUGAR NG KAPANGANAKAN BARANGAY CITY / MUNICIPALITY PROVINCE

C.7 CELLPHONE
C.6 HOME PHONE NUMBER
NUMBER
C.8 RELIGION / RELIHIYON C.9 E-MAIL ADDRESS
C.10 TAX IDENTIFICATION - - - 0 0 0 -
C.11 SSS NUMBER
NUMBER (TIN)
C.12 UNIFIED MULTI-PURPOSE - - C.13 GSIS NUMBER
ID
C.14 ASSOCIATION
1. 2. 3.
MEMBERSHIP (TOP 3 ACTIVE)

D. PRESENT ADDRESS / KASALUKUYANG TIRAHAN ( If same as others, blacken the Same as Comelec Address
appropriate circle on the right. /Kung kaparehas ng iba, itiman ang akmang bilog sa kanan. )
D.1 HOUSE/LOT/BLOCK/
BUILDING NO. & NAME
D.2 STREET / ROAD /
AVENUE
D.3 SUBDIVISION / PUROK

D.5 YEARS OF RESIDENCY IN MUNTINLUPA /

D.4 BARANGAY
Ilang taon ka ng nakatira sa Muntinlupa?

E. PERMANENT ADDRESS / PERMANENTENG TIRAHAN ( If same as others, blacken the Same as Comelec Address
appropriate circle on the right. /Kung kaparehas ng iba, itiman ang akmang bilog sa kanan.) Same as Present Address
E.1 HOUSE/LOT/BLOCK/
BUILDING NO. & NAME
E.2 STREET / ROAD /
AVENUE

E.3 SUBDIVISION / PUROK

E.4 BARANGAY

E.5 CITY/MUNICIPALITY

E.6. PROVINCE E.7 ZIPCODE

F. FAMILY BACKGROUND / DETALYE NG PAMILYA

Please shade the circle below if you will declare the following as beneficiary/ies. / Itiman ang bilog kung gusto niyong gawing beneficiary/ies ang mga sumusunod.
LAST NAME / APELYIDO FIRST NAME / PANGALAN DATE OF BIRTH / PETSA NG AGE AT THE TIME OF CAUSE OF DEATH /
KAPANGANAKAN (MM/DD/YYYY) DEATH / EDAD NANG DAHILAN NG PAGKAMATAY
FATHER's NAME / Pangalan ng TATAY NAMATAY
/ / years old

HOMETOWN ADDRESS / TAGA-SAANG PROBINSIYA

BARANGAY CITY / MUNICIPALITY PROVINCE

MOTHER's MAIDEN NAME / Pangalan ng NANAY sa Pagkadalaga
/ / years old

HOMETOWN ADDRESS / TAGA-SAANG PROBINSIYA

BARANGAY CITY / MUNICIPALITY PROVINCE

SPOUSE's MAIDEN NAME / Pangalan ng ASAWA sa Pagkadalaga
/ / years old

HOMETOWN ADDRESS / TAGA-SAANG PROBINSIYA

BARANGAY CITY / MUNICIPALITY PROVINCE

G. NAME OF CHILDREN / PANGALAN NG MGA ANAK For Non-Single: None / Walang Anak For Single: Not Applicable / Hindi akma
Please shade the circle below if you will declare the following as beneficiary/ies. / Itiman ang bilog kung gusto niyong gawing beneficiary/ies ang mga sumusunod.
DATE OF BIRTH / AGE AT THE TIME CAUSE OF DEATH /
PETSA NG
LAST NAME / APELYIDO FIRST NAME / PANGALAN KAPANGANAKAN
OF DEATH / EDAD DAHILAN NG
(MM/DD/YYYY) NG NAMATAY PAGKAMATAY
1ST / / years old
CHILD
2ND / / years old
CHILD
3RD / / years old
CHILD
4TH / / years old
CHILD
5TH / / years old
CHILD
*If the number of children is more than five (5), please write the succeeding details in a separate sheet. / Kung ang bilang ng mga anak ay higit sa lima (5), paki-sulat ang mga sunod na
detalye sa hiwalay na papel.

H. EMPLOYMENT / TRABAHO Unemployed / Walang Trabaho

H.1 PRESENT OCCUPATION /
KASALUKUYANG TRABAHO
H.2 EMPLOYER / PANGALAN NG
PINAGTRATRABAHUHAN
H.3 WORK ADDRESS / LUGAR NG
PINAGTRATRABAHUHAN
BARANGAY CITY / MUNICIPALITY PROVINCE

I. Undertaking:
By signing this form, I agree and affirm that: / Sa pagpirma ko nito, pumapayag ako at nagsasabi na:
- I have read, understand and agree to abide by the terms and conditions stated in the Muntinlupa Care Card (MCC) Rules & Regulations. /
Nabasa, naunawaan at sinasang-ayunan ko ang mga kondisyon, alituntunin at regulasyon na nakasaad sa Muntinlupa Care Card (MCC).
- I confirm that all information provided on this form is true and accurate. / Pinagtitibay ko na ang lahat ng impormasyon na nakasulat dito ay
totoo at eksakto.
- I understand that the MCC may undergo reasonable changes from time to time as circumstances require. / Naintindihan ko na ang MCC ay
maaring magkaroon ng pagbabago kung kinakailangan o kung hinihingi ng pagkakataon.
- I understand that the MCC will store information provided about me and my family which is appropriate for the smooth function of the MCC.
/ Naintindihan ko na ang MCC ay magtataglay ng impormasyon tungkol sa akin at sa aking pamilya para sa maayos na operasyon ng MCC.
- I allow the use of my information for related activities. / Pinapayagan ko ang paggamit ng impormasyon tungkol sa akin para sa mga gawaing
may kaugnayan sa MCC.

/ /
Signature Over Printed Name Date Signed (MM / DD / YYYY) Please affix right thumbmark if
unable to write

*** For Authorized Personnel Used Only: (Please do not write below this page. / Pakiusap huwag sulatan ang mga nasa ibaba.) ***

Initial Encoding: / / : AM / PM
Signature over printed name M M D D Y Y Y Y H H M M

Form Verification: / / : AM / PM
Signature over printed name M M D D Y Y Y Y H H M M

Cashier: / / : AM / PM
Signature over printed name M M D D Y Y Y Y H H M M

Picture Capture: / / : AM / PM
Signature over printed name M M D D Y Y Y Y H H M M

Released By: / / : AM / PM
Signature over printed name M M D D Y Y Y Y H H M M
MUNTINLUPA CARE CARD - Application Form (Part 3) CONTROL NO.: -

File Copy ACCIDENTAL INSURANCE

J. Terms & Conditions (Insurance Benefits/Coverage) /
MGA BENEPISYO AT SAKLAW NG INSURANCE:
J.1. Accidental Death Benefit (Php 10,000). If within one hundred eighty (180) days from the date of accident, such injuries result in death
of the Insured Individual. / Benepisyo ng pagkamatay sanhi ng aksidente (Php 10,000). Kung sa loob ng isang daan at walumpung (180) araw
mula sa petsa ng aksidente, ang nasabing pinsala ay magreresulta sa pagkamatay ng isinegurong (Insured) Indibidwal.
J.2. Motorcycling Coverage (Php 10,000). Coverage for accidental death or disablement sustained while riding any two-wheeled motorized
vehicle. / Saklaw habang nakasakay sa motorsiklo (Php 10,000). Saklaw sa pagkamatay dahil sa aksidente o pagkabaldado habang nakasakay sa
anumang uri ng sasakyan na may dalawang gulong na pinapagana ng motor.
J.3. Permanent Total Disablement (Php 10,000). Payable once an Insured becomes disabled permanently, totally and absolutely from
engaging in his or her occupation or employment for compensation within twelve (12) calendar months of bodily injury and not followed
within twelve (12) calendar months of said bodily injury by death, the Company will pay for the loss of: / Tuluyang Pagkabaldado (Php
10,000). Pwedeng bayaran ang Insured kapag permanenteng nabaldadong ganap at walang pasubali, mula sa kanyang trabaho o
paghahanapbuhay para sa kabayaran sa loob ng labindalawang (12) buwan sa kalendaryo nang pinsala sa katawan nito at hindi tumalima sa loob
ng labindalawang (12) buwan sa kalendaryo ng sinabi pinsala sa katawan sa pamamagitan ng kamatayan, ang kumpanya ay magbabayad para sa
kawalan ng:
Description of Disablement / Paglalarawan ng Pagkabaldado Percentage / Bahagdan
Both hands or both feet or sight of both eyes / Dalawang kamay o dalawang paa o paningin ng dalawang mata 100% = Php 10,000
Total and permanent loss of sight in one eye / Ganap at permanenteng pagkawala ng paningin sa isang mata 50% = Php 5,000
Total loss by physical severance or total and permanent loss of use of: / Kabuuang kawalan ng pisikal na
pagkahiwalay/pagkalagot o ganap at permanenteng pagkawala ng paggamit ng:
Two limbs (arms or legs) / Dalawang Biyas (braso o binti) 100% = Php 10,000
One limb (arm or leg) / Isang Biyas (braso o binti) 50% = Php 5,000
J.4. Accidental Burial Expense (Php 1,000). The Policy will pay on top of the Accidental Death benefit up to the benefit limit stated in the
policy for burial expense following death directly or solely attributable to the accidental bodily injury. / Gastos sa pagpapalibing (Php 1,000).
Maliban sa benepisyo ng pagkamatay dahil sa aksidente, ang policy ay magbibigay ng benepisyo hanggang Php 1,000 para sa gastos ng libing.
J.5. EXCLUSIONS. The Policy shall not extend to cover: / MGA HINDI KABILANG. Ang hindi saklaw ng Policy:
J.5.1. Death or disablement occasioned by or happening through: / Pagkamatay o pagkabaldado dahil sa mga sumusunod:
(i) War, Invasion, Act of Foreign Enemy, Hostilities (whether war be declared or not), Strike, Riot, Civil War, Rebellion,
Revolution, Insurrection, Mutiny, Military or Usurped Power, Military or Popular Rising; / Digmaan, panghihimasok, Pagsasagawa
ng Dayuhang Katunggali, Pakikipagdigmaan (kung digmaan ay ipinahayag o hindi), Welga, Kaguluhan, Digmaang Sibil, Paghihimagsik,
Pag-aalsa, Insureksyon, Mutiny, Militar o Pagkamkam ng Kapangyarihan, Militar o Popular Rising;
(ii) Suicide or Attempted Suicide (sane or insane), Alcoholism, or Insanity; / Pagpapakamatay o pagtangkang pagpapakamatay
(matino o di matinong pag-iisip), Alkoholismo, o Pagkabaliw;
(iii) Earthquake, Volcanic Eruption, or Tidal Wave; / Lindol, Pagsabog ng Bulkan, o Agwahe;
(iv) Any weapon or instrument employing atomic fission or radioactive force, whether in time of peace or war. / Anumang
sandata o instrumentong gumagamit ng “atomic fission” o “radioactive force”, kahit na oras ng kapayapaan o digmaan.
J.5.2. Death or disablement caused by murder or assault (provoked & unprovoked) or any attempt threat. / Kamatayan o pagkabaldado
dahil sa pagpatay o pag-atake (naudyukan man o hindi) o kahit anong tangka.
J.5.3. Death or disablement occurring whilst the Insured is operating or learning to operate or serving as a crew member of an aircraft
or sea craft. / Kamatayan o pagkabaldado habang ang “Insured” ay nagpapatakbo, natututo o nagseserbisyo bilang kawani ng mga sasakyang
panghimpapawid o pangdagat.
J.5.4. Death or disablement occasioned by or happening through pregnancy or childbirth with respect to women. / Kamatayan o
pagkabaldado habang nagbubuntis o nanganganak para sa mga kababaihan.
J.5.5. Death or disablement caused while the Insured is performing or attempting the performance of an unlawful act. / Kamatayan o
pagkabaldado habang ang “Insured” ay nagsasagawa o nagbabadyang magsagawa ng gawaing hindi alinsunod sa batas.
J.5.6. Death or disablement whilst the Insured is engaged in any dangerous sports or hobbies such as racing on wheels, glider flying,
sailing or other hobbies which are comparably dangerous and risky. / Kamatayan o pagkabaldado habang ang “Insured” ay nagsasagawa
ng anumang mapanganib na “sports” o libangan katulad na pakikipagkarera ng mga sasakyang may gulong, “glider flying, sailing” o kahit na
anong libangan na maihahalintulad bilang mapanganib at peligroso.

/ /
Signature Over Printed Name Date Signed (MM / DD / YYYY)
Please affix right thumbmark if
unable to write
MUNTINLUPA CARE CARD - Application Form (Part 3) CONTROL NO.: -

Resident's Copy ACCIDENTAL INSURANCE

J. Terms & Conditions (Insurance Benefits/Coverage) /
MGA BENEPISYO AT SAKLAW NG INSURANCE:
J.1. Accidental Death Benefit (Php 10,000). If within one hundred eighty (180) days from the date of accident, such injuries result in death
of the Insured Individual. / Benepisyo ng pagkamatay sanhi ng aksidente (Php 10,000). Kung sa loob ng isang daan at walumpung (180) araw
mula sa petsa ng aksidente, ang nasabing pinsala ay magreresulta sa pagkamatay ng isinegurong (Insured) Indibidwal.
J.2. Motorcycling Coverage (Php 10,000). Coverage for accidental death or disablement sustained while riding any two-wheeled motorized
vehicle. / Saklaw habang nakasakay sa motorsiklo (Php 10,000). Saklaw sa pagkamatay dahil sa aksidente o pagkabaldado habang nakasakay sa
anumang uri ng sasakyan na may dalawang gulong na pinapagana ng motor.
J.3. Permanent Total Disablement (Php 10,000). Payable once an Insured becomes disabled permanently, totally and absolutely from
engaging in his or her occupation or employment for compensation within twelve (12) calendar months of bodily injury and not followed
within twelve (12) calendar months of said bodily injury by death, the Company will pay for the loss of: / Tuluyang Pagkabaldado (Php
10,000). Pwedeng bayaran ang Insured kapag permanenteng nabaldadong ganap at walang pasubali, mula sa kanyang trabaho o
paghahanapbuhay para sa kabayaran sa loob ng labindalawang (12) buwan sa kalendaryo nang pinsala sa katawan nito at hindi tumalima sa loob
ng labindalawang (12) buwan sa kalendaryo ng sinabi pinsala sa katawan sa pamamagitan ng kamatayan, ang kumpanya ay magbabayad para sa
kawalan ng:
Description of Disablement / Paglalarawan ng Pagkabaldado Percentage / Bahagdan
Both hands or both feet or sight of both eyes / Dalawang kamay o dalawang paa o paningin ng dalawang mata 100% = Php 10,000
Total and permanent loss of sight in one eye / Ganap at permanenteng pagkawala ng paningin sa isang mata 50% = Php 5,000
Total loss by physical severance or total and permanent loss of use of: / Kabuuang kawalan ng pisikal na
pagkahiwalay/pagkalagot o ganap at permanenteng pagkawala ng paggamit ng:
Two limbs (arms or legs) / Dalawang Biyas (braso o binti) 100% = Php 10,000
One limb (arm or leg) / Isang Biyas (braso o binti) 50% = Php 5,000
J.4. Accidental Burial Expense (Php 1,000). The Policy will pay on top of the Accidental Death benefit up to the benefit limit stated in the
policy for burial expense following death directly or solely attributable to the accidental bodily injury. / Gastos sa pagpapalibing (Php 1,000).
Maliban sa benepisyo ng pagkamatay dahil sa aksidente, ang policy ay magbibigay ng benepisyo hanggang Php 1,000 para sa gastos ng libing.
J.5. EXCLUSIONS. The Policy shall not extend to cover: / MGA HINDI KABILANG. Ang hindi saklaw ng Policy:
J.5.1. Death or disablement occasioned by or happening through: / Pagkamatay o pagkabaldado dahil sa mga sumusunod:
(i) War, Invasion, Act of Foreign Enemy, Hostilities (whether war be declared or not), Strike, Riot, Civil War, Rebellion,
Revolution, Insurrection, Mutiny, Military or Usurped Power, Military or Popular Rising; / Digmaan, panghihimasok, Pagsasagawa
ng Dayuhang Katunggali, Pakikipagdigmaan (kung digmaan ay ipinahayag o hindi), Welga, Kaguluhan, Digmaang Sibil, Paghihimagsik,
Pag-aalsa, Insureksyon, Mutiny, Militar o Pagkamkam ng Kapangyarihan, Militar o Popular Rising;
(ii) Suicide or Attempted Suicide (sane or insane), Alcoholism, or Insanity; / Pagpapakamatay o pagtangkang pagpapakamatay
(matino o di matinong pag-iisip), Alkoholismo, o Pagkabaliw;
(iii) Earthquake, Volcanic Eruption, or Tidal Wave; / Lindol, Pagsabog ng Bulkan, o Agwahe;
(iv) Any weapon or instrument employing atomic fission or radioactive force, whether in time of peace or war. / Anumang
sandata o instrumentong gumagamit ng “atomic fission” o “radioactive force”, kahit na oras ng kapayapaan o digmaan.
J.5.2. Death or disablement caused by murder or assault (provoked & unprovoked) or any attempt threat. / Kamatayan o pagkabaldado
dahil sa pagpatay o pag-atake (naudyukan man o hindi) o kahit anong tangka.
J.5.3. Death or disablement occurring whilst the Insured is operating or learning to operate or serving as a crew member of an aircraft
or sea craft. / Kamatayan o pagkabaldado habang ang “Insured” ay nagpapatakbo, natututo o nagseserbisyo bilang kawani ng mga sasakyang
panghimpapawid o pangdagat.
J.5.4. Death or disablement occasioned by or happening through pregnancy or childbirth with respect to women. / Kamatayan o
pagkabaldado habang nagbubuntis o nanganganak para sa mga kababaihan.
J.5.5. Death or disablement caused while the Insured is performing or attempting the performance of an unlawful act. / Kamatayan o
pagkabaldado habang ang “Insured” ay nagsasagawa o nagbabadyang magsagawa ng gawaing hindi alinsunod sa batas.
J.5.6. Death or disablement whilst the Insured is engaged in any dangerous sports or hobbies such as racing on wheels, glider flying,
sailing or other hobbies which are comparably dangerous and risky. / Kamatayan o pagkabaldado habang ang “Insured” ay nagsasagawa
ng anumang mapanganib na “sports” o libangan katulad na pakikipagkarera ng mga sasakyang may gulong, “glider flying, sailing” o kahit na
anong libangan na maihahalintulad bilang mapanganib at peligroso.

/ /
Signature Over Printed Name Date Signed (MM / DD / YYYY)
Please affix right thumbmark if
unable to write