Fortune Life Building

162 Legaspi st. Legaspi Village

1229 Makati City, Philippines
MCPO 4781
Tel. Nos.: 892-9841 to 49 (connecting all departments)
Fax No.: 891-3343 Telex No.: 23255 Basic PH
E-mail: fortlife@fortunelife.com

April 7, 2022

MS. ANGIE LEA B. SERRA

C/O Dagupan

Subject: Full Withdrawal of Premium Deposit Fund (PDF)

Under Policy No. 000229001-04-1 of Serra, Angie Lea B.

Dear Ms. Serra;

To form part of your Policy Contract, please acknowledge receipt of the registered deletion
of your Premium Deposit Fund (PDF) through a Request for Amendment Form.

CUSTOMER SERVICE DIVISION

Received by:

(PLEASE SIGN OVER PRINTED NAME)

(DATE RECEIVED)

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