No.

_____________
PhilLife Financial Assurance Corporation
G/F, 8F – Penthouse, iAcademy Plaza, 324 Sen Gil J. Puyat Ave., Makati City
Tel. No. (632) 798-54-33
TIN 007-884-680-000

REQUEST FOR CONVERSION, RELEASE OF DIVIDENDS, PCF/PDF WITHDRAWAL, ACER

BENEFITS, REFUND, CASH SURRENDER VALUE, MATURITY BENEFITS
(for Individual Policy)
Privacy Policy: Philippine Life Financial Assurance Corporation ("PhilLife") guarantees that the personal information and sensitive
personal information provided by the Life Insured/Policy Owner will be treated with utmost confidentiality and it shall use said information
only for the specific purposes for which they were obtained within the limits provided by law and its implementing rules and regulations.

Customer Information:
Policy Owner
Life Insured
Policy Number
Address

Tel No. (Landline) Cellphone No. Email Address

TIN SSS/GSIS

Application: I hereby request PhilLife to effect the change(s) specified below. I certify that the information I provided in this form are
full, complete and true, and they shall be the basis of the Company’s evaluation of the change(s) specified here. When PhilLife approves
it, I further request that the change(s) be endorsed in the policy.

Request (please tick (
) requested change(s); write “n/a” if not applicable)
 Conversion to Extended Term Insurance  Conversion to Reduced Paid-up Insurance  Withdrawal of dividends

 Payment of ACER benefits/Pure Endowment  Refund of excess payment  PCF/PDF withdrawal

 Cash Surrender  Payment of Maturity benefit

In support of this request, I am submitting the following documents and verified copies of my IDs:
 Policy contract  Endorsement  Affidavit

 ID (1)  ID (2)  Others

Payment Instruction (Applicable to all requests except Conversion to either ETI, RPU, or permanent plan)
If payment of proceeds is by direct deposit, please choose one: I authorize PhilLife to deposit the proceeds of this Request to my
bank account: (Bank Charge: Amount below P10k ,P 50.00 and above P10k , P100. They may change depending on the actual cost incurred.)

 Union Bank  Banco de Oro  BPI  Metrobank  Landbank

Account No.: ______________________________________  Savings  Current

Authorization
I authorize PhilLife, its officers and employees, to use my personal information and sensitive personal information that I disclosed in this
Request, including those which I may give thereafter in respect of such application, for purposes of changing the policy. When my
Request is approved by PhilLife, I further authorize PhilLife, its officers and employees to use the information about me in administering
my coverage, customer servicing, and other legitimate further processing for historical, statistical, or scientific purposes, and in other
cases laid down by law.

This authorization takes effect on the date I signed this Application and shall remain effective until it is expressly revoked by the
applicant or Life Insured.

Declaration
By affixing my signature, I hereby acknowledge that the Request has been fully explained to me by my life insurance agent or by a
representative of PhilLife.

Signatures
___________________________________
Signature over printed name of Policy Owner

Date _______________________________

If a beneficiary is irrevocable, such beneficiary must give consent.

________________________________ ________________________________ ________________________________

Signature over printed name of beneficiary Signature over printed name of beneficiary Signature over printed name of beneficiary

Date____________________________ Date____________________________ Date____________________________

Form No. RFCFP0022272019001