NoticeofCancellation

Date :____________________

To :COCOLIFEPolicyServiceDepartment
CocolifeBuilding
6674AyalaAvenue,MakatiCity

Re :

VLPolicyNo.___________________

I wish to cancel my variablelifeinsurance coverage, please refund to me the total

PremiumChargesandInsuranceChargespaidandtheAccountValue.Attachedis
thepolicycontract.
Citedbelowarethereasonsforthecancellation:
1.________________________________________________________
2.________________________________________________________
3.________________________________________________________
4.________________________________________________________
5.________________________________________________________

________________________________
Signatureofapplicantoverprintedname

Signatureofirrevocablebeneficiaries
ifapplicable:

1.______________________________

2.______________________________

3.______________________________

POL_ADMIN03408071