PNB Life Insurance, Inc.

Policy No. P
FUND TRANSFER AGREEMENT

P _______________________________ representingthethe
I hereby agree that the amount of (Php/USD)_________________________________________representing
P _______________________________________willl
proceeds of my________________________________________________ will be
be transferred
transferred to
to my
my account,
account,with
with
details indicated below:

Bank Name: P For Allied Bank account holders,

please see important advisory
underscorred below
Bank Address/Branch: P
Account
Bank Account Number:
P Currency:
P
(Please indicate exact account name)
Bank Account Name:
P
If Joint Account:
Co-depositor's Name: Type of
Account: and / or and
(Please check 1 box)

If Payroll Account with Allied Banking Corporation:

Please provide SSS Number
(mandatory information requirement)
Peso Mode of Transfer and Charges for other bank transfers i.e. account to be credited is not with Allied
Banking Corporation or Philippine National Bank. Please select one.
RTGS - Same Day Transfer Printed Name and Signature of Policyowner:

with fee of PHP500.00 for FT Signature

Verified
value of less than less than
PHP40 million
RTGS - Same Day Transfer Printed Name and Signature of Policyowner:

with fee of PHP800.00 for FT Signature

Verified
value of greater than / equal
to PHP40 million
Printed Name and Signature of Policyowner:
PCHC - 3 Day Transfer Signature
Verified
with fee of PHP250.00
DATE: PRINTED NAME AND SIGNATURE OF POLICYOWNER:
P P I certify that the information provided hereon is complete and correct.

Signature

Verified
IF I AM AN ABC ACCOUNT HOLDER, I HAVE READ AND AGREE TO THE FEES
THAT WILL BE CHARGED ME

P MANDATORY FIELDS WHERE APPLICABLE, SHADED FIELDS ARE MANDATORY FIELDS

USE OF CORRECTION FLUIDS / TAPES ARE PROHIBITED. FOR ANY ALTERATIONS, PLEASE DRAW A
STRAIGHT LINE ACROSS ERRONEOUS DATA, TO WHICH PLEASE POLICYOWNER MUST AFFIX HIS/HER FULL
SIGNATURE. CORRECT INFORMATION MAY THEN BE INDICATED BESIDE OR ABOVE IT

IMPORTANT ADVISORY FOR ALLIED BANK ACCOUNT HOLDERS :

IF YOUR ACCOUNT IS OUTSIDE OF METRO MANILA, THE FOLLOWING ABC FEES SHALL BE DEDUCTED FROM
YOUR PROCEEDS:
PHP VALUES: PHP 100.OO FOR TRANSFER VALUE OF UP TO PHP100,000. ADDITIONAL
PHP50.00 FOR EVERY INCREMENTAL VALUE OF PHP100,000.00- OR FRACTION THEREOF.
EX. PHP90,000.00 = FEE OF PHP100.00, PHP100,050.00 = FEE OF PHP150.00,
PHP251,000.00 = FEE OF PHP200.00
USD VALUES: USD2.00 FOR EVERY USD2,000.00 OR FRACTION THEREOF.
EX. USD1,500.00 = FEE OF USD2.00, USD 4,500.00 = FEE OF USD6.00