Cash Surrender Request Form - Philam Life

CASH SURRENDER REQUESTPlease fully accomplish this form and present documents listed at the back.1. POLICY DETAILSPolicy No.Policyowner: ________________________________Address: ______________________________________________________________________________Email address _______________________________Insured: _____________________________Phone No. ___________________________Cellphone no. _________________________TIN: ________________________________SSS/GSIS:___________________________2. REASON FORSURRENDERWill the proceeds for this request be used to fund a new policy? Yes No ________________If yes, with what Company? <strong>Philam</strong> life Policy No. _______________ __________________ Policy No. _______________REMINDER FROM THE INSURANCE COMMISSION ON REPLACEMENT OF POLICY:"It is usually disadvantageous to REPLACE existing life insurance policy(ies) with a new one.Some disadvantages are:* You may not be insurable on standard terms.* You may have to pay a higher premium in view of a higher age* You may lose financial benefits accumulated over the years.Please note that in your own interest, we would advise that you double-check with an agent or acompany representative of your present insurer, whether it is PHILAM LIFE or another company,before making a final decision. Hear from both sides and make a careful comparison. You can then besure that you are making a decision that is in your best interest.”3. SURRENDERAMOUNT<strong>Surrender</strong> Amount: _________________As of: _________________________4. AUTHORIZATION This is to authorize my representative, with proper identification papers and whose specimen signatureappears below, to receive from <strong>Philam</strong> <strong>Life</strong> for and in my behalf the cash surrender value of this policy.________________________________________Authorized Representative’s Name and Signature________________________________________Policyowner’s Name and SignatureIdentification Presented: ______________________________________________________________5. SIGN HERE FORABOVE REQUESTIn consideration of this policy’s cash surrender value, I/we hereby release and surrender all rights, title, andinterest unto THE PHILIPPINE AMERICAN LIFE AND GENERAL INSURANCE COMPANY and agree toindemnify 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 <strong>Philam</strong><strong>Life</strong> which issued this contract is fixed and limited to such cash surrender value and any credits, and upon itspayment, shall be completely discharged. It is expressly warranted that no other person, partnership orcorporation has any interest whatsoever in said policy and that no insolvency or bankruptcy proceedings arepending for or against the undersigned.Place of Signing: ___________________________________Date: ___________________________________________________________________Signature over Printed Name of Policyowner_______________________Witness_______________________ _______________________ _______________________Irrevocable Beneficiary Irrevocable Beneficiary AssigneeTO BE FILLED OUT BY PHILAM LIFE PERSONNELCurrency: Peso US Dollar Received by: ________________________________Document Received: Branch/Office: ________________ Date: ________ Policy ContractApproved by: ________________________________ ID Branch/Office: ________________ Date: ________ Others __________________________________________________Processed by: ________________________________Branch/Office: ________________ Date: ________PHILAM LIFE CUSTOMER CONFIDENTIALQR-PBAO-CSRRev 6Mar 2011

INSTRUCTIONS AND CONDITIONS1. POLICY DETAILS Please complete this section to facilitate identification of the policyowner details and tobe able to facilitate communication with you.2. REASON FORSURRENDERIf you are replacing the contract with a new one, ask your agent for a comparison toenable you to review the benefits of each plan.May we advise you to carefully assess your decision. Review and compare to ensurethat your final decision would be to your best interest.3. AUTHORIZATION Please complete this section if the proceeds will be claimed by a representative and notby the policyowner.4. SIGN HERE FORABOVE REQUESTPlease indicate the date and place of signed. This must be signed by the policyownerand the irrevocable beneficiaries and assignee.The witness portion must be duly signed by a third party of legal age.The policyowner will be the payee in the check representing the surrender proceeds.DOCUMENTS TO BEPRESENTEDRequired documents:• Policy Contract• Policyowner’s Identification CardsPlease provide additional requirements for special circumstances as indicatedbelow :• If Policyowner is not present, the authorized representative must present a validID of representative authorized to receive the surrender proceeds on behalf of thepolicyowner residing in the Philippines• If Policyowner is abroad, the authorized representative must present a currentSpecial Power of Attorney duly authenticated by the Philippine Consul. If thiscannot be obtained, proceeds may be deposited to the policyowner’s local bankaccount subject to an authorization letter addressed to the bank with the bankdetails.• If with minor irrevocable beneficiary, the minor’s guardian can sign for thebeneficiary who is a minor if the share in the surrender amount does not exceedP50,000.00, If the share exceeds P50,000.00, this application must beaccompanied by letters of Guardianship and a Court Order, authorizing thesurrender of the Policy.• If Owner or Assignee is a corporation, an officer of the corporation must sign forthe corporation on the <strong>Cash</strong> <strong>Surrender</strong> <strong>Request</strong> form. This must be accompaniedby a Corporate Secretary’s Certificate or Board Resolution authorizing thesurrender of the policy and giving the executing officer authority to sign thissurrender request on behalf of the corporation.• If the Policy Contract is lost, please submit this form together with a dulyaccomplished a duly notarized Indemnity Agreement for <strong>Cash</strong> <strong>Surrender</strong> <strong>Form</strong>which indicates the date signed and singed by witnesses. A minimal rewriting feewill be required.QR-PBAO-CSRRev 6Mar 2011PHILAM LIFE CUSTOMER CONFIDENTIAL