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Bond Application Form
GSIS application form for individual/single proprietorship bond
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INSURANCE GROUP
GOVERNMENT SERVICE INSURANCE SYSTEM
BOND APPLICATION
(For Individuals/Single Proprietorships)
The undersigned hereby applies for a _____________________________________________________________ bond in the amount of
____________________________________________________________ in favor of________________________________________________ to
fully and faithfully guarantee _____________________________________________________________________________________________
_______________________________________________________________________________________________________________________
(Indicate details of undertaking or obligations to be guaranteed by bond applied for, or attach a copy of principal contract
and pertinent documents, under the terms of which the bond applied for is required)
For your consideration, I am giving hereunder the following information:
1.
2.
3.
4.
5.
6.
7.
Name
Civil Status
Nationality
Residential Address
Tel. No.
Office Address
Tel. No.
What is your occupation? ____________________________________________________________________________________________
How long have you been engaged as such? _____________________________________________________________________________
What is your monthly salary or income? ________________________________________________________________________________
If you engaged in business, please describe its nature and state the income monthly or annually, that you derive from this source _______
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
8.
Do you have any savings or checking account? If so, in what bank and what is the present balance? _______________________________
_________________________________________________________________________________________________________________
9.
If you own real estate properties, please give the following particulars: If land state if titled or unregistered, whether residental, commercial
or agricultural and also area thereof. If building, state number of storeys, nature of occupancy (residential, store, bodega, etc.) and type of
construction (concrete, timber, light materials, etc.)
Description
Location
Assessed Value
Market Value
a)
P
P
b)
P
P
c)
P
P
d)
P
P
10.
If any of the above mentioned properties is/are presently mortgaged, please state name of mortgage, amount of original loan, present
balance and when due: _____________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
11.
Do you carry fire insurance on any of those properties? If so, with what company and for what amount? ___________________________
_________________________________________________________________________________________________________________
12.
Do you own stocks of companies listed in the Manila Stock Exchange? If so, state name of issuing company, kind and number of shares
owned and current value thereof. _____________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
13.
If you carry life insurance, state how much, in what company, the beneficiary, how long has the policy been in force and approximate value
thereof:
_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
(over)
Bond Application
14.
Are you indebted, besides mortgage, to anyone for sums of money? If so, state name of creditor, how much on what account and when due:
____________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
15.
State whether you are co-maker in a loan, indemnitor in a bond undertaking, or guarantor for anyone and to what extent? ____________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
16.
Have you ever had a bond cancelled, or an application declined by any surety company? When and why? __________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
17.
If you have ever before given bond, state particular in following spaces:
Name of Surety
18.
Type of Bond
Amount
Name of Obligee
Date Terminated
Give below names, occupations, and address of responsible persons for reference in no case naming relatives:
Name
Occupation
Address
The above and foregoing statements and representatives are true and correct to the best of my knowledge and belief,
knowing that on the basis of which the GSIS shall be guided in considering this bond application.
Dated at ______________________________________________ this _________________ day of _________________________ 20_____
Signature
REPUBLIC OF THE PHILIPPINES)
)
_________________________)
S.S.
SUBSCRIBED AND SWORN to before me this __________________ day of __________________, 20___ in ________________________,
affiant exhibited to me his/her Res. Cert. No. A&B ______________________ issued at ___________________ on _______________________.
Doc. No.
Page No.
Book No.
Series of
NOTE:
;
;
;
;
Please attach copy of your latest income tax return
NOTARY PUBLIC
Until December 31, 20_________ Until
PTR No.
Issued at
On
