AUTHORIZATION FOR PAYROLL DEDUCTION

ENTITY NAME:
ADDRESS:

EMPLOYEE NAME (print in full):

Last Name First Name Middle Name

TO THE PAYROLL OFFICER:

I authorize you to deduct from my monthly / semi-monthly salary/ service fee the amount indicated below to
be paid to Insular Life.

Please effect the

initial deduction of
Amount to be deducted Php ___________________ this premium on

Total deduction for Insular Life Php ___________________ Date

This authorization shall cease upon written notice upon written notice by me of the cancellation of this
authority, or upon my separation from service.

I acknowledge that any amount deducted from my payroll/ remuneration under this authorization shall only
have the effect of payment if the same is duly remitted to and received by Insular Life.

Employee Name & Signature

Address:_______________________
_________________________________