Personal Financial Statement - Pru Life Uk
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PERSONAL FINANCIAL STATEMENT
Mr/Mrs/Miss/Title
Life Assured (Last name, First name, Middle name)
Mr/Mrs/Miss/Title
Applicant (Last name, First name, Middle name)
Dependents*
Age
Relationship
Financial Worth
Real Estate
Location/Address
Residence
Estimated Current Worth*
Php
Rented
Owned
Rented
Owned
Rented
Owned
Php
Total Worth of Real Estate:
* Write on the space provided: MR - Monthly Rent; MP - Market Price; PP - Purchase Price; MA - Mortgage Amount.
Securities (e.g. bonds, cash items, stocks)
Securities (Type and Description)
Estimated Current Worth
Php
Php
Total Worth of Securities:
Approximate Income
Income
Estimated Income Current Yr.
Estimated Income Last Yr.
Net Earned Income
Net Investment Income
Source Earned income
Php
Php
Total Income Earned:
Other Assets (e.g. model of cars owned)
Description of Properties
Estimated Current Worth
Php
Php
Total Worth of Properties:
Dated at _________________________ this _____ day of ____________________, 20 ______.
I declare that the answers given above are true and correct to the best of my knowledge and belief, and I agree
that this questionnaire shall form a part of my application for assurance.
Signature over Printed Name of WITNESS
Signature over Printed Name of LIFE INSURED
Signature over Printed Name of WITNESS
Signature over Printed Name of APPLICANT
NB-PFS-0602
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Parent category: Financial