You are on page 1of 1

Tick the box for the appropriate

Plan Type and write Plan Number or


Complete Name Nationality Agreement Number appearing in
the Policy Contract or Certificate of
Full Payment

Tick the box beside the request


that you are filing. For CARE/EAB,
select Others and write the request
in the space provided.

Indicate the date and place this


document was accomplished

Print name and sign over it using


your long and short signature forms
(if you are using 2 signatures), then
indicate the date.

Put the name of the agent who


assisted you. Cross it out if none.

To be accomplished only if you


bought a new plan using the
proceeds of your maturity benefits.

For PhilPlans’ office use

You might also like