Balance Protect Application Form

Personal Information
Note: Individual coverage is until 60 years old only
Credit Card Information
Contact Information
Health Information
I am in good health and have never suffered from, received advice or treatment for nor have any indication of: cancer, cancerous growth/tumor, chest pain, heart attack, high blood pressure, stroke, diabetes, hepatitis, any disorder of the heart, lung, liver, kidney, spine, joints, digestive system, mental or nervous disorder, blood disorder, endocrine disorder, disorder of eyes, alcoholism, drug abuse, AIDS or AIDS related complications. 
Within the past five years, I have not been admitted nor been advised to be admitted as an inpatient in a hospital or clinic except for a routine health check-up, cold, influenza, hepatitis A, upper or lower respiratory tract infections, gall bladder/kidney stones, tonsillectomy, herniotomy, gastroenteritis, appendectomy, cholecystectomy, haemorrhoidectomy and pregnancy / birth.  
I have never had an insurance application or insurance policy declined, rated up, postponed, accepted on special terms or rescinded due to misrepresentation and/or concealment.
Thank You Page

Thank you for your interest in applying!

 

Upon our review, in line with the Terms and Conditions of the program, we regret to inform you that you did not pass the eligibility requirements.

 

Thank you.

You're one step closer
Beneficiaries
While coverage is in force, FWD will pay your outstanding balance until your date of demise. Any death benefit remaining after this payment will be given to your nominated Primary Beneficiary and Contingent Beneficiary (if the Primary Beneficiary is deceased).


Declaration
By signing and submitting this Application Form for Insurance, I understand and expressly consent to the following:

1. The information and answers that I have provided in the Application Form, this Application Form and any attached document/s (collectively known as “Forms”) are complete and true. I acknowledge that FWD may nullify my Insurance if I have provided inaccurate or incomplete information or answers.

2. FWD may collect, use, and store the information provided in these Forms to process this application and to service my policies.  The information gathered may be shared with FWD’s third parties and any medical information sharing facility, as may be necessary. These information (including those which will be available during the life of my policies) may further be processed and shared for policy issuance and administration, claims adjudication, data analytics, historical and scientific research, profiling, risk management, enhancement of products and services, identity verification, protection against fraud, and to comply with legal, regulatory, or contractual requirements. I acknowledge that in certain instances, my information may be processed through automated means. 

3. I understand that FWD reports to its parent company located in Hong Kong and Singapore may engage third-party service providers and partners who, in some instances, may be located outside the Philippines. As necessary, my personal and policy information may be processed, shared, stored, and be subject to the laws of these foreign jurisdictions. FWD and its affiliates, third-party service providers and partners, are required to protect the confidentiality of my personal information in a manner consistent with data protection principles.

4. I authorize FWD to disclose my personal and financial information to FWD Group and any government or tax authority (within or outside the Philippines) for the purposes of ensuring FWD’s and FWD Group’s continual compliance with applicable laws, regulations, guidelines and good market practices. 

5. FWD may contact me to request or clarify information to process this application, send me policy information, and perform other relevant activities to service my policies. 

6. I attest that the consent of the Beneficiary/ies and all other data subjects in this Application form were obtained by me for the processing of their information for purposes listed above.    

Privacy Policy: 
Your privacy is a priority for FWD.  The Company keeps your personal information about you and the products and services you have with us in confidence. For more information about our Privacy Policy, kindly visit our website at https://www.fwd.com.ph/en/privacy-policy. You may also email our Data Protection Officer at [email protected] for any privacy concerns related to your information provided to us.

I expressly consent to the foregoing Data Privacy Declaration and understand that my failure or refusal to give consent may result to the denial of, or inaction of this Balance Protect Insurance application.
Authorization
1. My insurance coverage will be in accordance with the terms and conditions of the Balance Protect Insurance Policy entered into by SBC with FWD.
  
2. To ensure continuous insurance protection, I authorize to automatically charged my credit card account to cover for the premium, if and when due.

3. I acknowledge that if by any case within the 1st year coverage I perform any activity that may result to self inflicted death/suicide, my insurance will be nullified and FWD will refund any premiums paid to my estate. 

4. I acknowledge that I have read, understand and agree to the laws, regulations, and guidelines on Anti-Money Laundering (AML) and Terrorism-Financing Prevention (TFP).

Search

AllHome - Agro
AllHome - Antipolo
AllHome - Bacolod
AllHome - Bataan
AllHome - Butuan
AllHome - Cabanatuan
AllHome - Cauayan
AllHome - CDO
AllHome - Cebu
AllHome - Dasmariñas
AllHome - Evia
AllHome - Gapan
AllHome - General Santos
AllHome - General Trias
AllHome - Global South
AllHome - Iloilo
AllHome - Imus
AllHome - Kawit
AllHome - Koronadal
AllHome - Las Piñas
AllHome - Libis
AllHome - Malolos
AllHome - Mintal
AllHome - Naga
AllHome - North Molino
AllHome - Pampanga
AllHome - QC
AllHome - QuickFix Camella East
AllHome - QuickFix Farm
AllHome - QuickFix M1 Annex
AllHome - QuickFix Masibay
AllHome - QuickFix Springville
AllHome - QuickFix Symphony
AllHome - QuickFix Venezia
AllHome - Salawag
AllHome - San Ildefonso
AllHome - Santiago
AllHome - Shaw
AllHome - Silang
AllHome - SJDM
AllHome - South Molino
AllHome - Sta. Maria
AllHome - Sta. Rosa
AllHome - Sto. Tomas
AllHome - Taguig
AllHome - Tanza
AllHome - WCC
AllHome - QuickFix Citta Italia

  • Aerophone - Ayala Center Cebu
  • Aerophone - Cybertech Quezon City
  • Aerophone - SM Cebu
  • Aerophone - SM Manila
  • Aerophone - SM San Lazaro

This will close in 0 seconds

  • CYA Industries Inc - Bacolod
  • CYA Industries Inc - CDO
  • CYA Industries Inc - Cebu
  • CYA Industries Inc Showroom - Shangrila
  • My Homedepot - Baliuag Tangos
  • My Homedepot - Alabang Zapote
  • My Homedepot - Angono
  • My Homedepot - Barrera
  • My Homedepot - Batangas
  • My Homedepot - Cabanatuan
  • My Homedepot - Calapan
  • My Homedepot - Caloocan
  • My Homedepot - Candelaria
  • My Homedepot - Candon
  • My Homedepot - Daet
  • My Homedepot - Dasma
  • My Homedepot - Fairview
  • My Homedepot - Guagua
  • My Homedepot - Gumaca
  • My Homedepot - Iba
  • My Homedepot - Imus
  • My Homedepot - Los Banos
  • My Homedepot - Malasiqui
  • My Homedepot - Marikina
  • My Homedepot - Mayapyap
  • My Homedepot - Nayon Nova
  • My Homedepot - Niog 3
  • My Homedepot - Novaliches
  • My Homedepot - Pasong Putik
  • My Homedepot - Olongapo
  • My Homedepot - Palanginan
  • My Homedepot - Pilar
  • My Homedepot - Paranaque
  • My Homedepot - Pulilan
  • My Homedepot - Roxas
  • My Homedepot - San Jose
  • My Homedepot - San Marcelino
  • My Homedepot - San Rafael
  • My Homedepot - Santiago
  • My Homedepot - Silang
  • My Homedepot - Sorsogon
  • My Homedepot - Sta Cruz
  • My Homedepot - Tarlac
  • My Homedepot - Taytay
  • My Homedepot - Urdaneta

This will close in 0 seconds

  • Petbuddy Antipolo
  • Petbuddy Bataan
  • Petbuddy Dasmariñas
  • Petbuddy Evia
  • Petbuddy Malolos
  • Petbuddy North Molino
  • Petbuddy South Molino
  • Petbuddy Springville
  • Petbuddy Sta. Rosa
  • Petbuddy Taguig

This will close in 3 seconds

  • Allbikes Evia
  • Allbikes Sta Rosa

This will close in 0 seconds

  • Allsports Bataan
  • Allsports Evia
  • Allsports Malolos
  • Allsports Nomo
  • Allsports Sjdm
  • Allsports Taguig
  • Alltoys Bataan
  • Alltoys Evia
  • Alltoys Malolos
  • Alltoys Nomo
  • Alltoys Sta. Rosa
  • Alltoys Taguig

This will close in 1 seconds

  • Finds - Bataan
  • Finds - Dasmarinas
  • Finds - General Trias
  • Finds - Iloilo
  • Finds - Las Pinas
  • Finds - Malolos
  • Finds - Naga
  • Finds - NOMO
  • Finds - Shaw Blvd.
  • Finds - SJDM
  • Finds - Sta.Rosa
  • Finds - Taguig

This will close in 0 seconds

  • Market Liberty - Evia

This will close in 0 seconds

  • No Name - Bataan
  • No Name - Dasmarinas
  • No Name - Pampanga
  • No Name - Sta. Rosa

This will close in 0 seconds

  • The Athlete'S Foot - Bataan
  • The Athlete'S Foot - Evia
  • The Athlete'S Foot - Sta Rosa

This will close in 0 seconds

  • Pull And Bear - Cebu
  • Pull And Bear - SM Megamall
  • Pull And Bear - Trinoma

This will close in 0 seconds

  • Zara - Cebu
  • Zara - Glorietta
  • Zara - Greenbelt
  • Zara - SM Megamall
  • Zara - SM Mall of Asia
  • Zara - ONE BHS, BGC
  • Zara - Rockwell
  • Zara - Shangrila
  • Zara - Trinoma

This will close in 0 seconds

  • Massimo Dutti - Greenbelt 5
  • Massimo Dutti - Rockwell

This will close in 0 seconds

  • Bershka - Cebu
  • Bershka - Glorietta
  • Bershka - Megamall
  • Bershka - Mall of Asia
  • Bershka - Shangrila

This will close in 0 seconds

  • Stradivarius - SM Aura
  • Stradivarius - Glorietta
  • Stradivarius - Megamall
  • Stradivarius - Shangrila

This will close in 0 seconds

  • Mandaue Foam - Butuan
  • Mandaue Foam - Cebu
  • Mandaue Foam - Banilad
  • Mandaue Foam - Bohol
  • Mandaue Foam - Cebu
  • Mandaue Foam - Quimpo
  • Mandaue Foam - Shaw Blvd.
  • Mandaue Foam - (Philfoam) Cainta, Rizal
  • Mandaue Foam - (Philfoam) Las Pinas
  • Mandaue Foam - (Philfoam) Lipa, Batangas
  • Mandaue Foam - (Philfoam) Quezon Avenue

This will close in 0 seconds

  • Our Builders Warehouse - Bocaue
  • Our Builders Warehouse - Guiguinto
  • Our Builders Warehouse - Mabalacat
  • Our Builders Warehouse - Malolos
  • Our Builders Warehouse - Tagaytay
  • Our Builders Warehouse - Dasmarinas

This will close in 0 seconds

  • 158 Designers Blvd - Pasay

This will close in 0 seconds

  • Anne Klein - Rockwell

This will close in 0 seconds

  • Armani Exchange - Rockwell

This will close in 0 seconds