OFFICIAL RECEIPT

Ground Floor, Philippine Axa Life Centre AXA Philippines is an affiliate of

Sen. Gil Puyat Avenue corner Tindalo Street Makati City P.O. Box 2390
Customer Hotline: (632) 5815-292 (AXA) | Website: www.axa.com.ph
NON-VAT REG. TIN 000-485-226-000

Received the Amount of Receipt Date

TWO THOUSAND FIVE HUNDRED PESOS AND FORTY CENTS ONLY October 02, 2019

Policy No.: 310-6904174

Payment For:
Premium Settlement PHP 2,500.40

Due Date: September 28, 2019 TOTAL: PHP 2,500.40

Payment in Form of :
PHP 2,500.40 By Cash

COLE ORFFA KIZHA CASSANDRA G Distributor Code: 60020404029597

DOK ALTERNATIBO DOOR 3 Distributor Type: Financial Executive
SANCHEZ BUILDING Cashier: PXRTABLADA
SANCIANGKO ST CEBU CITY OR Number: 14714551
CEBU PROVINCE 6000
8189534324

We appreciate your business. Thank you for your confidence in AXA, the worldwide leader in financial protection.
BIR E-RECEIPTING PERMIT NO. 1011-116-00164 CBA /AR DATED 10-18-2011

CONDITIONS MENTIONED ON FACE HEREOF

1. This receipt shall not be binding on the company for any part of said payment covered by
check or any form of remittance other than cash, unless remittance is promptly honored upon
presentation of payment.

2. If this payment is not acceptable for the purpose it is offered, it will be returned accordingly
following the normal course of business.

3. This payment shall be treated as premium only if the policy to which this payment is intended
to is approved and if it is sufficient to satisfy the required premium payment. Else, this shall
be treated as a deposit until such time that all conditions mentioned are met.

4. This payment, if sufficient, shall be applied to the premium due on the policy provided that
such policy is in force on the date of payment. In case this payment is insufficient, or the said
policy has lapsed before this payment, the amount receipted shall be treated as deposit until
the amount due is paid in full within the grace period and/or until the said policy, if lapsed,
is reinstated.

5. No person, except an executive officer, with at least a Vice-President level, of the Company is
authorized to make, alter or discharge contracts or waive forfeitures.