BENEFICIARY CONSENT FORM

________________________________________________________________________
Philippine Prudential Life Insurance Co., Inc.
[ Section1]
INFORMATION ABOUT POLICY & INSURED

Policy No. __________________ / / Individual / / Group

Last Name First Name M. I.

___________________________ ______________________ _____

ADDRESS: [STREET & DISTRICT] NOTE: TO BE COMPLETED IF THERE IS A CHANGE OF ADDRESS

__________________________________________________________________________________________

CITY/MUNICIPALITY: POSTAL CODE:

_______________________________ _____________

CONTACT NUMBERS:

Landline: / / Office _____________ / / Residence ______________

Mobile Number: _______________ Email: _______________

________________________________________________________________________
[ Section2 ]
CONSENTMENT OF THE CURRENT IRREVOCABLE BENEFICIARY

I, ____________________________________ the beneficiary in the policy contract identified

in Section 1 above on “Information About Policy & Insured”, hereby waive my irrevocable
status and/or consents to the proposed action of the Insured which may include the following
– / / Change Of Designated Beneficiary, or / / the surrender of the policy contract,
or such other act as__________________________________________________________.

X
_____________________________________ / / / /
Irrevocable Beneficiary Signature Date Signed

WITNESS MY HAND AND

BEFORE ME, A NOTARY PUBLIC FOR AND IN __________________ NOTARIAL SEAL.
PERSONALLY CAME THE HEREIN NAMED BENEFICIARY WHOM
I HAVE IDENTIFIED TO BE THE SAME PERSON SIGNING BY THE
PRESENTATION OF COMPETENT EVIDENCE OF IDENTIFICATION This day of .
CONSISTING OF - ____________________________________.
HE/SHE CONFIRMED THAT HIS/HER SIGNATURE WAS AFFIXED
FREELY AND VOLUTARILY AND THE ACT AS HIS/HER FREE
ACT AND DEED. Notary Public