i) GN prepane Lire Bap NEATIER LATER POLICY FUND WITHDRAWAL FORM "EF 1a SEO (emma Ho! Lena Bag) Bt Soars comer 30M Stent Banksia aba Cy, Tag 1S srctonie POLICY NUMBER: ore pat nner Ras one bce ” al Tempe) atiee (one I I I ( TT [a LI I I sisi | Senter O ESE AGORESS SiS ST TR ROT RESTO ee aie ox | oy owes cet “rst ont | oy Peta it sar i vary il J oo Nee Ne I emeeeam ee owme ()LELLI D) \WTHORAW PREMIUM DEPOT ANOUNTING 0: TI ete By whl easements, rn slap yo yb aca ‘ane. REDEMPTON Pectage Aman ‘eur utopia empton mybe made nts ONE ee flowing Pera, Ack rember Un L I I ane ] eee [ oO Ol CI * [ (ted wy Bark Aco Row Ate tne Assen Re ern CE. Typedtaccomt | svmgs crea loam ac ans 3H FamtyBaxsreneh enya run ates dere nx apteaor. acowedye ala payer ty Pham Lite oft poate is apatan Pra he cham Ihave deat oe shat feeate ard ere dschare Pram Letom a Scions, cams ch demas onal mars ian he sal beret acu. Fre, ely Mecorecnes fe 3c acy ‘dtheaooreintaraton|ponded Pia Lean urea a any repay ray case cry te assert Ne es ORPOS PRY / REVISION 1 / AUGUST 2020 ‘one tansaciors Presse specty LL ™—™—C™*“*S oo Apa rrp i ede bot cr Foi Ovne ef Pian sans hata one ot te snerettene ark aca monte an cle nur anna cane rsehac mugh = Account Oxparinion |_| paso ota PHILAM LIFE CUSTOMER CONFIDENTIAL,Tis expesty epeseiod and waar Dat oer peer expan tes ay sex Hn S40 coma exept Te Hed a Ha Hele ae na NSA anmuney Hoccangpeicny apa be uactegHed mad — om PED TT I| If ‘mers sat over Pres are eocabe Bereteiry soiree agen ess (ther Requests and Special ntructions READERS Wthdrmal rience may hav an foc en your cuert ion otn eth poly on so euppot er on aes fai wp odton "Ts eovershiraal on be fir nd ot We seteren find ffm excess amen made PARTIALINVESTHENT FUND WATHORAWAL “The aroun ofredareon wl be cakulted by mute the rumba fits ob deemed tom cach inestnert Fund bya Uni: Pie bazadon the asic rt. IF {he aime f nts par hindsro neste ine ‘orm, usta be edeemes shal ben report oe Fund arson er ucen My efectas oe te edema ‘lees subes apphealerevertin hag Paral winraale wl te lewedprovied hee ne condone amet. "heute af ederpeania wih re mnimun sons +The mnivam blanco cach urs a ae the redemption \itoraval of nds ate nvestnetprectens or assumplns shown nthe Mstabn of Benetsample Preposa (GENERAL REQUREMENTS ‘Paley ners idneatin Cds ‘iremocale Coren eran Cats Pease se ast equrerenis below fr pec cirursarces “iffy Our srt poe, ease pear avail De Re tepresrtatve ahorce eve the euor wha poceedson beat he Paley Onn eng inte Ptgores ‘ltPoley Oarer's bad lense sum acuren Spec Power of Atomey uly ashes bythe Phiprne Corsi thiscannet be ota reccecs my be “posted whe Poi Caner socal bark ccoum the! autottion ete aiessud one bn, neatng bar tals ‘tbat nor veaceble ney the mrt caren sha er Ae Lega Guneseh pan ign ts newestieencin/< chav doce to ced Sago ne hae exceeds 30000 Coen apcaln ustbe accompated by ais cf Gutdarenip aa Cau Cds, along fe ander fe Plc, asst SerecingTansered Jigen Code ‘ite Our or henge a apron an fe te compre mus fe copeion ners, andi at aecompanid by 2 Capers Sacco cect anu dort Raoaion auhorang te mbweawalono plcy ahd ging to weet ee’ aay o gn Rs abutment tua on bhal ‘be sopereren ‘Seton 2516 Insurance Code, as ave, mposesa ne not xccedngtice the amour daredarde mpsret otto @) years, fbf at he dsceten of tne cout ary persone pesertsoreaises tobe reseed ary favavert arn ude 3 east of naan ato FaLddeny prepares, Waker S.DSabes ay laning wf rienttoprsentorur the sare orf slowitiae eesesd sippy doen ‘TO BE FILLED BY PHILAM LIFE PERSONNEL Hwimessed ay anagert, neste t ‘geal || Reneatng seer Seratue DesetingSenchgTaetered secon: ees By ate Docu Processed By Date BrachOtice Poqrovet By ate bonchiOtice te OR-POS PRY / REVISION 1 / AUGUST 2020POLICY OWNER’S CONSENT AND WAIVER FORM LIFE 1. The Company and its affliates (‘the Group’) are subject to and required to or has agreed to, comply with certain legal, regulatory andlor other requirements in respect of Anti-Ncney Laundering and Counter Terrorist Financing ("AML"), Know Your Client (‘KYC") andior as set out pursuant to the US Foreign Account Tax Comoliance Act (‘the Reporting Requirements") as well 13s other laws and regulations which now or which may in the future come into effect. As such, Uwe provide our express consent that tne Company shall have the rignt to provice such personal ata and information to any governmental authorities, regulatory bodies and/or any other pperson(s), both local and foreign, in respect of the Reporting Requirements including the United Stales Internal Revenue Service. llwe understand that such disclosures may involve the cross border transfer of personal data outside the jurisdiction and that such disclosures may be with respect to |) the personal data of the Owner, the Contingent Owner, the Insured, and the Beneficiaries (the Parties”), or any of them: i) any information relating to this Policy: and fi) any information reiating to any other policies held by the Patties or any of them. LWe understand that the Company will not be able to sell any insurance product to me/us and provide any service we refuse to give the said express consent. 2. Account Holders who have or may have US Indicia The below paragraph applies only to (i) US persons for US federal income tax purposes; or (i) Hf your tax status changes and you became US Person: or (ii) You or Beneficiaries in connection. with this Policy have incicated through information provided fo us that you or such beneficiary may be in fact a US person for US federal income tax purposes (including for example a US ‘address, a US telephone number, a TIN, etc.) The term "US Indiciat” as used below refers to any ‘one of the three circumstances described in(') to (ii) above. In the event you have US indicia and fail after request to provide such information, consent, and or assistance as the Company may from time to time reasonably require to allow it to cormply with its contractual, legal andlor regulatory obligations under the United States Foreign Account Tax Compliance Act, including any required reporting to the Internal Revenue Service of information relating to you or Beneficaries in connecticn with this Folicy, the Company reserves the right and shall be entitled to cancel this Policy (subject to Sections 48 and 233(b) of the Insurance Code) and return the higher of: a all paid premiums, or b) the Cash Value or Account \Value ofthis Policy, in consideration of such termination. 3. UWe hereby declare and agree that, by purchasing this Policy and signing below, /We represent that We are not a “US person” for US federal income tax purposes and that we are not acting for, or on behal of, 2 US person. IWe understand that the Company believing this statement to be true, will rely on it and act on it In the event this statement is false, the Company reserves the ‘ight and shall be entitled to cancel this Policy (subject to Sectons 48 and 233 (b) of the Insurance Code) and return to me/us the higher of : a) all paid premiums, or b) the Cash Value or ‘Account Value of this Policy, in consideration of such termination. If myfour tax status changes and UWe become a US Person, we must notify the Company within 30 days. (This clause is not applicable to US Citizens or residents who must compiele IRS Form W-8). A false statement or rmisrepresentation of tax status by @ US person could lead to penalties under US law. Place Signed Date Signed (MMI DD/YYYY) ‘eciizy Owner's Signature over Printed Wame Polley Number @R-CGC-POGW / REVISION 1 / APRIL 2014 PHILAM LIFE CUSTOMER CONFIDENTIAL,Desr Valued Client, Your rust andl confidence is mpetant to us. To ensure that Pham Life remains a trustworthy partner n your joumey towards financial securty and prospenty, we are making every effort fo comply ful wih te existing laws and regulations thal gover us. + ncomptance withthe Creat Infomation System Act, please be infomed that should you have any loan or ere faclty with us, Phila Lif © mandatod to share your basic code data including lated updates/ corrections fo the Cred Information Corporation (CIC) and other entities authorized under the law, even without your consent ++ ncomptance with RA-10173 also known as the Philippine Data Privacy Act of 2012, whose implementing Rules and Regulations took effect on September 9, 2076, Phaiam Life's sencing you tis fete to update you and secure your consent. Please send back the dy signed off form ether tough your Financial Advisor. a Phin Lfe branch near you, ora Scanmed copy via emai at hi. phiamprivacy@eva.com, ‘Should you have questions or concems about the Data Privacy consent form, please call 526-2000 or emai us af ph plamorivacyta's com For mare information on how Pham Lie protects is cata, You may vist aur Prvacy Statement at wiry phlamife com or type this ink to Your browser: ito wun. phlamife comenindexarvacy-statement Hird. Snoorely yours, Prion tito DATA PRIVACY CONSENT In compltanco win the Data Privacy Act (DPA) of 2012, and ts Implementing Rules and Rogulatons (IRR) effective since Seplembor 8, 2016, "alow The Phitppine American Life and General insurance Company (Phslam Life) 1o provide me cartan services declared in relation tothe insurance poicyles | purchased ‘As such, agree and authorize Pfam Life Company to 1. Continue to use my and my polises' information to process insurance services and administer the benefts as stated in my polieytes) 2. Retain my information fra period of seven years rom the date of termination of my polcy, ot such time that I submit to Pilam Life a ion cancion of ths consent whichovors ear. | goreo that my information wil bo dolotod/destioyod ator tis poiod 3. Relain my information in the Medica Information Database shared with other life insuranee compari in aocoréance with the Insurance Reauiston 4. Share my information to alates and necessary tid parties for any legitimate business purpose. | am assured thal security systems are ‘employod to prtoct my information. 5. Inform me of future customer campaigns and base its offer using the personal iformstion | shared withthe company. also acknowedge and warrant tht have acquired the consent froma parties relevantto this consent and hold fee and harmless and indemnity Pri Life rom any complart, su, or damages which any party may fle or clam in ration tomy consent Sign this__day of. 20__at wy Saga oer RNATE Yeas owec Senator Prieta amen ‘Should you have questions or concomns about this consont fom, ploase call S28.2000 or mall us at pi pilamprivacy@aia.com. For moe infomation on how Phiam Life protects its data, you may vst our Privacy Statement at wav pitamife com or type ths Ink to your browser: hip: /iwsw philamife comvenindexinnvacy statement Rim MARKETING CONSENT Katy chock () appropriate box to indicate your consent. vi YES, | alow Prilam Lfe andi’ third party agents (ex. Financial Advisor to use my personal information for future customer campaigns. 190, donet alow Phlam Life and i's third party agents (ex Financial Advisor to use my persona infomation fr future customer campaigns QR-CGCO-DPI/REVISION 1/ OCTOBER 2017