_ &PhilLife puaronm wo, 2016001 CLIENT REQUEST FORM NAME: Policy Ne. Employee No Datel/Time: ‘Address: ‘Contact No Branch/Region TYPE OF TRANSACTIONS (please check the box) (1 REFUND, Specify it for (] Loan (J Premium — Months Applied for Refun Deposit to Bank: Payroll account only Bank Account No.: (© Check for pick up in PhilLife Financial Branch Specify Branch: ‘Type of Loan Refund and conditions (please read) {a Excess from Renewed loan - wil be processed as soon as the new deduction takes effect (2 to 3 months from billing date). b. Excess from Fully-pai loan and Others — will be facilitated as soon as remitted by DEPED to Phllife Financial ©. Advance Payment ~ will be refunded as soon as the deduction of the new loan takes effect. 4. ONLY the TEACHERICLIENT/ASSURED can receive the Refund Check. Cc wiTHDRAWAL [_]PoLicy LOAN CClbeaTH claim [cash SURRENDER [_lotners ‘Signature over printed name of Authorined Representa ve REQUIREMENTS: © CERTIFIED TRUE COPY OF ATM CARD by Phillfe Financial BSA (DEPED Payroll Account ONLY) with 3 ORIGINAL specimen signatures (_PHOTOCOPY OF AT LEAST 2 VALID IDs (DEPED ID, PRC, ETC.) with 3 ORIGINAL specimen signatures (PHOTOCOPY OF CURRENT PAYSLIP ‘authorized representative: Submd an Authorization letter to PROCESS REQUEST FOR REFUND only and copy of VALID ID of Representative VERIFIED BY BSA: RECEIVED By: DATE: DATE:‘Form No, See.Comm_052018_ V1.0 REQUEST AND WAIVER ON THE USE OF ELECTRONIC CHANNELS FOR OFFICIAL COMMUNICATION , 1 residing st ____, ereby request chat unt ts ‘aatruction is evoked by tne personally Through an original signed docareal, all official instetions and communication with Philippine Lite Financial Assurance Corp. (Phe) ia connection with my Insurance Policy and/or Leas Product shall be coursed through any ofthe electoaic channels | specified below. understand that this Instrocion, when approved by PhilLife Head Office, shall everide the communicetton fasrvetions Inthe Appieation for Loan andlor Application for insurance, ss the case may be: { MY OFFICIAL DEPED E-MAIL ADDRESS 1 (Write email address below. One letericharactr per box) I MY OFFICIAL CELL PHONE NUMBER FOR SMS (Write fll cell pbone auraber/s) below. One number por box.) For and in consideration of PhILfes gran ofthis request, I acknowledge and agree that: 1. 1am solely rexpousfble for maintaining the confidentiality and integrity of sccess to the above indicated coal address. 1 shall immediately notify PhLife Lf the sald email adress has boen discontinued, deactivated, or if | have reason to belive that such email account has been hacked or if any unauthorized third party has gained access to this emall account 2. Tam solely responsible for maintaining the integrity and security ofthe cell phone number tha I have provided. {shall immediatly notify PPhilL.ife if this cell phone number has been discontinued, deactivated, or compromised In ay way, whether through the theft ofthe phone izing said number or through otber methods. Tam solely and fully responsible forall instructions, communiestion, transactions, and activities that occur through the use of any of the ‘channels indicated above. { shall notify PiILif through altemative comauncation means (¢.g telephone callin writing, or persoaal visitto any PhilLife branch office) in ease T receive a non-delivery report exail or SMS when trying to ead an email or SMS to PBIILI. 5. Any notice, enail or SMS, reparding my Loan Account ant Insurance Product from PhilLife provided tome through these channels shall ‘be considered as oficial notice for enforcement of the Loan Agreement and/or Policy Contact and compliance with applicable law. This shall be without prejudice othe sending to me of notice through regular postal mal atthe particular address 1 have provided inthe Loan ‘Application or Policy Contact. All other Inforcution which may be transmined to me vis these channels will be provided only for my convenience, but should not be deemed offical. Any eror o discrepancy between the information trasmited via these channels and te official records of PiLife shall ‘ol in any way prejudice or give rise to any liability on the part of PhifLfe 1 PhilLife shal take reasonable security precautions forthe transmission of coofidential information over these channels. However, Phil.if6 ‘shall not be ible for any interception of any such data or communication which may occur beyond the reasonable control of Phil. f. [Neither PILI nor any ofits service partners, employees, or ageos shall be responsible for any damages caused by communications line flue, systems failure or other occurrences beyond their con. Phil shall tlze the foregoing sity in connection with tbe rasinteance of my Polly/Loen Product and shall ata ies abide by te Dus Privacy Act of2012 and allt clevet implementing rules, regulations end guidelines. 9. Phil.fe may be contacted trough its officiel electronic communication channels pasted at worn plf.com ph, | 1 Bigratare Over Priied Nae "FOR HEAD OFFICE USE ONLY Request Evaluation: By: Tianati