CASH SURRENDER FORM

HELPING PEOPLE LIVE HEALTHIER, LONGER, BETTER LIVES 16F-18F Six/NEO (formerly Net Lima Building), 5th Avenue corner 26th Street, Bonifacio Global City, Taguig 1634

Agent Code

POLICY NUMBER
NOTE: Fill out with block letters. Put on the tick boxes representing options.

PART I - CONTACT INFORMATION UPDATE

I agree to update my contact information record with Philam Life based on the details in this section.
LAST NAME Telephone : Residence Office

( ) - ex:
(044) 123-4567
FIRST NAME Mobile Phone
+ 6 3 - - ex:
+63-900-1234567
MIDDLE NAME E-Mail Address

RESIDENTIAL ADDRESS: If you want to receive e-notices in lieu of hard copy billings, accomplish the E-Notice Enrollment Form
House / Building / Lot No.,
Name of Street

District City Province Zip Code

BUSINESS / EMPLOYER ADDRESS:

House / Building / Lot No.,
Name of Street

District City Province Zip Code

Date of Birth (DD/MM/YYYY) Place of Birth Nationality

Sex Male Female Gender Male Female

(defined as gender at the TIME OF BIRTH) (defined as gender at the TIME OF CLAIMS APPLICATION)

Occupation and Name of Employer

(if self employed, the nature of the self employment/business activity) Type of ID:

ID Number:

PART II - REQUESTED TRANSACTION

FINAL MATURITY FULL REDEMPTION (FOR VUL)

SURRENDER POLICY CANCELLATION WITHIN COOLING-OFF PERIOD (FOR POLICY)

Rider:
SURRENDER RIDER WITH CASH VALUE CANCELLATION WITHIN COOLING-OFF PERIOD (RIDER) Note: Indicate Rider

Indicate reason for Surrendering/Full Redemption/Cancellation: This is a REQUIRED field

WHAT YOU SHOULD KNOW ABOUT THE SURRENDER OF YOUR POLICY

An insurance policy is intended to meet your long term protection and financial needs. In surrendering your Policy, you will inevitably lose its valuable benefits and you may not be
able to obtain a similar level of protection on the same terms in the future. Replacing your Policy with another policy, could result in higher premiums and loss of specific features or
protection due to changes in age and/or health conditions. You may incur new charges and the periods under the "incontestability" and "suicide" provisions may start anew under
the new policy.
-You have several options to consider aside from surrendering your policy:
1) Apply for a Policy Loan or an Automatic Premium Loan to keep your policy Inforce.
2) Convert your Policy to Reduced Paid Up Insurance or Extended Term Insurance.
3) Exercise a Fund Switch, or Partial Withdrawal of Investment Funds.

PART III - PAY OUT OPTION

Credit to my Bank Account Note: Applicable bank charges may be deducted from the proceeds.

Bank: Account Number:

Type of Account: Savings Checking Account Denomination: Peso Dollar

Account Name: Branch of Account:

Claim at any BPI / BPI Family Bank Branch Note: Applicable bank charges may be deducted from the proceeds.

I certify that I am a Policy Owner of Philam Life and that I am the owner of the aforementioned bank account number and mobile number and that I can be reached through the
mailing address declared in this application. I acknowledge that the payment by Philam Life of the proceeds of this application through the channel I have designated above, shall
release and forever discharge Philam Life from all actions, claims and demands on all matters involving the said benefit or amount. Further, I certify the correctness and accuracy
of the above information I provided Philam Life and I understand that any discrepancy may cause delay in the disbursement of the proceeds.

PLEASE DO NOT SIGN ON A BLANK FORM

QR-PBAO-CSR / REVISION 8 / AUGUST 2020 PHILAM LIFE CUSTOMER CONFIDENTIAL

 PART IV - SIGNATURE
In consideration of this policy's cash surrender/account value, I/we hereby release and surrender all rights, title, and interest in this Policy unto the Philam Life and agree to
indemnify and protect said Company from all claims and demands under this policy and from all losses, costs, and expenses incident to defending itself against such claims and
demands. The liability of Philam Life which issued this contract is fixed and limited to such cash surrender/account value and any credits, and upon its payment, shall be completely
discharged. It is expressly warranted that no other person, partnership or corporation has any interest whatsoever in said Policy and that no insolvency or bankruptcy proceedings
are pending for or against the undersigned.

m m d d y y y y

Place Signed Date: / /

Owner's Signature over Printed Name Irrevocable Beneficiary Assignee Agent / Witness

Other Requests and Special Instructions

REMINDERS
ANTI-FRAUD WARNING
Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or imprisonment of two (2) years, or both, at the discretion of the
court, to any person who presents or causes to be presented any fraudulent claim under a contract of insurance, and who fraudulently prepares, makes or subscribes any writing
with intent to present or use the same, or to allow it to be presented in support of any claim.

GENERAL REQUIREMENTS
• Policy Owner’s Identification Cards
• Irrevocalbe Beneficiary's Identification Cards
Please see additional requirements below for special circumstances:
• If Policy Owner is not present, please present a valid ID of the representative authorized to receive the surrender proceeds on behalf of the Policy Owner residing in the
Philippines
• If Policy Owner is abroad, please submit a current Special Power of Attorney duly authenticated by the Philippine Consul. If this cannot be obtained, proceeds may be
deposited to the Policy Owner’s local bank account subject to authorization letter addressed to the bank, indicating bank details.
• If with minor irrevocable beneficiary, the minor's guardian shall submit Affidavit of Legal Guardianship and sign if the irrevocable beneficiary's share does not exceed 500,000.
If the share exceeds 500,000.00, this application must be accompanied by letters of Guardianship and a Court Order, authorizing the surrender of the Policy.
• If the Policy Owner or Assignee is a corporation, an officer of the corporation must sign for the corporation on the disbursement form, and this must be accompanied by a
Corporate Secretary’s Certificate and Board Resolution authorizing the withdrawal on the policy and giving the executing officer authority to sign this request on behalf of the
corporation.

TO BE FILLED BY PHILAM LIFE PERSONNEL

If witnessed by an agent, indicate if: Original Reinstating Agent Signature

Assisting/Servicing/Transferred Agent Code:

Received By Date Documents submitted together with this application:

Branch/Office

Processed By Date

Branch/Office

Approved By Date

Branch/Office

Notes:

QR-PBAO-CSR / REVISION 8 / AUGUST 2020