CERTIFICATE OF LIFE INSURANCE

XYZ LIFE INSURANCE CORPORATION

POLICY INORMATION

POLICY Number: Life Insurance Policy No. B-89241 Date: January 6,

2015

GENERAL INORMATION

Policy Initial Owner/Applicant: Daniel Lagdameo

Residence Address: 527-L, Sambag I, Urgello, Cebu City
Gender: Male
Birthday: September 10, 1959
Civil Status: Married
Birthplace: Purok Nagmahal, Brgy. Dao, Pagadian City
Age of Applicant at Issuance of Policy: 56
Name of Employer:
Nature of Business:
Estimated Annual Income:
Mobile Phone:
Business Address:
Business Phone:

INFORMATION OF THE PERSON'S LIFE INSURED

Policy Initial Owner/Applicant: Daniel Lagdameo

Residence Address: 527-L, Sambag I, Urgello, Cebu City
Gender: Male
Birthday: September 10, 1959
Civil Status: Married
Birthplace: Purok Nagmahal, Brgy. Dao, Pagadian City
Age of Applicant at Issuance of Policy: 56
Name of Employer:
Nature of Business:
Estimated Annual Income:
Mobile Phone:
Business Address:
Business Phone:

POLICY DETAILS

Effectivity Date: Maturity Date:

BENEFICIARY
Named Primary Beneficiary: Isabel Lagdameo
Relationship: Daughter of Policy Owner
Revocable or Irrevocable: Irrevocable

Named Secondary Beneficiary: Amelia Lagdameo

Relationship: Daughter of Policy Owner
Revocable or Irrevocable: Irrevocable

SUMMARY OF BENEFITS PAYABLE

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 ACKNOWLEDGMENT

I acknowledge that I have applied with XYZ LIFE INSURANCE CORPORATION

for an Insurance Policy and have reviewed the provisions showing how a life
insurance policy performs using the company's assumptions based on the
Insurance Commissioner's guidelines on interest rates.

I likewise understand that the performance of fund may vary, the values of my
units are not guaranteed and will depend on the actual performance of a given
period.

I understand that the risks of investment under this policy shall be borne by me,
as the policy owner.

DANIEL LAGDAMEO
Applicant

January 6, 2015
Date signed