COMPANYS LETTERHEAD FORM NO.

1 LETTER OF APPLICATION FOR ELIGIBILITY TO BID FOR THE REINSURANCE OF GSIS ISSUED POLICIES _______ _________ Date The Chairman GIBAC GSIS Bldg., Pasay City Sir : The undersigned Declarant, _______________________ (Full Name), of legal age, _____________ national with residence at __________________, in his capacity as __________________ (Position) of the ________________________ (Name of Applicant Firm), and in accordance with the Instructions to Applicants for eligibility, hereby states that: 1. 2. The Declarant is legally authorized to act in the name, and for the account, of the Applicant, (i) The full name and address of the Applicant is :

_______________________________________________________________ (Name and Address of the Applicant) 3. Pursuant to the attached written authority/Resolution of the Governing Board of the Applicant (Annex 1), the undersigned Declarant applies, for and in behalf of the Applicant, for eligibility to bid for the reinsurance of GSISIssued Insurance Policies. By this letter, the Applicant, by and through the undersigned Declarant, hereby declares/acknowledges, without qualification, that :

4.

(a)

The GIBAC and/or its duly designated representative shall have full authority to conduct any investigation to verify the statements, documents and information herewith submitted, for this purpose, this application, among others, shall serve as full authorization for any public official, engineer, accountant, officer, agent, representative, trustee, bank, depository, or any other person or firm in the confidence of the Applicant to furnish all pertinent information deemed necessary and requested by the GIBAC or its representative to verify statements and information provided in this application or regarding our competence and standing. The Applicant is fully aware of, and unconditionally accepts, the dates and periods fixed or to be fixed by the GIBAC for the Eligibility Check, Tendering and Award of Contract, renouncing consequently any request for extension. The Applicant has vested the Declarant with full powers and authority to execute agreements and to effect all necessary formalities, for and in behalf of the Applicant, for the Eligibility Check and tender, including the acceptance of award and execution of the necessary contract, by virtue of the Power of Attorney/Board Resolution issued by the Applicant. The Applicant(s) sworn affidavit that they are not related to the head of the procuring entity by consanguinity or affinity up to the third civil degree, in compliance with the Disclosure Provision under Section 47 of RA 9184. The GIBAC has the full right without need of justification other than that allowed in the Instructions to Applicants for Eligibility: (i) To declare ineligible or disqualify any Applicant who failed to submit or accomplish the required documentation, and to disqualify any applicant or bidder at any stage of the proceedings for violation of laws, rules and regulations that are intended to protect the integrity of the bidding process;

(b)

(c)

(d)

(e)

(ii) (iii)

To evaluate the qualifications of eligible applicants who will be requested to submit Technical and Financial Bid Proposals To deny request for reconsideration of rules, procedure and decisions adopted by the GIBAC or of the results of the Eligibility Check and tender on grounds that are not made manifest in the eligibility documents or bid proposals submitted; and To reject any or all bids or to declare failure of the bidding for any reason that, in the GIBACs sound judgment, may be in the best interest of the GSIS and the Assured.

(iv)

5.

The undersigned declares that the statements made and the information provided in this application are complete, true and correct in every detail.

Signature Name For and in behalf of : (Name of Applicant) Republic of the Philippines ) Province/City of _________) SUBSCRIBED AND SWORN to before me this _______ day of __________, ________, at ____________, affiant having exhibited his/her Community Tax Certificate No./Passport No. ___________ issued on _______________ at ____________________. Notary Public PTR No. ________________ Until ___________________ Doc. No. ______; Page No. ______; Book No. _____ ; Series of ______.