Withdrawal/Surrender Request Form
Variable Life Insurance Policy
POLICY DETAILS: Please fill in appropriately
Policy Number ID Type Presented and Details
Policy Owner ID Presented ID No. Valid Until
Address
Please ensure IDs presented are government-issued, valid, current primary
Contact Number IDs with pictures and attach clear photocopies thereof to this form.
REQUEST FOR A WITHDRAWAL FROM THE POLICY
I would like to request for a partial withdrawal from my policy:
From (Indicate Source Fund) Amount/Percentage/Units Notes:
- Please indicate the name of the fund and the corresponding percentage/
amount to be withdrawn.
- In order to process a withdrawal, the minimum amount taken
from the source fund must not be less than the minimum amount set by
the Company OR must equal the entire fund value. In addition, the
remaining value in the fund (if applicable) must also meet the minimum
amount set by the company.
- Withdrawals will be subject to the Company’s existing rules, charges
and applicable deductions.
- Please note that units will be cancelled based on redemption prices
applicable on the next pricing date.
REQUEST FOR FULL SURRENDER OF POLICY
I would like to request to fully surrender my policy.
The Policy Owner hereby gives notice to the Company of his/her intention to surrender his/her Policy for its Full Surrender Value.
Upon receipt of the proceeds representing the full payment of all my rights, title and interest over the Policy, I hereby release, remise and forever discharge BDO Life Assurance
Company, Inc./BDOLAC, its stockholders, directors, officers, employees, agents, representatives or assigns, from any and all liability, action, causes of action, suits, damages, etc., of
whatever nature and kind, whether civil, criminal or administrative, which I had, now have, or may have, arising out of or necessarily connected with my interests in said policy. I am
returning with this form the corresponding Policy for cancellation.
Please note that units will be cancelled based on redemption prices applicable on the next pricing date. Withdrawals will be subject to Company’s rules and deductions.
PAYMENT INSTRUCTIONS: Please choose payment instruction.
Apply to premium due on policy number/s __________________in the amount of _____________________________________.
Apply to outstanding policy loan on policy number/s (indicate no. & amount) _________________________________________.
Issue a check payable to me and:
I will claim the check personally from your head office
I will send my authorized representative, _________________________________ to claim the check
Please ensure your authorized representative has a letter of authorization from you and a valid government-issued ID when claiming the check.
Mail the check to my designated mailing address
Course the check through my servicing Financial Advisor (FA)/Agent, __________________________________
Please give your FA/Agent a letter of authorization for presentation when claiming the check.
Please credit to my account (I agree that any charges imposed by the bank to effect the transfer will be deducted from the proceeds).
BDO Branch Account No. Account Name
Please secure a proof of account document from your bank branch to ensure the proceeds are deposited properly. For joint accounts, the Policy Owner hereby assures
BDOLAC that payment into this account will extinguish the Company of all obligations related to the payment.
SIGNATURE AUTHORIZATION
I hereby attest that there are no other persons, firms or corporations with any interest in the abovementioned Policy aside from those expressly indicated above. I also attest
that there are no bankruptcy or insolvency proceedings pending on the belowsigned policyowner. Finally, I also attest that all signatories below are of legal age.
Signature over Printed Name of Policy Owner Date/Place of Signing Signature over Printed Name of Financial
Advisor/Agent/Staff to Witness
Signature over Printed Name of Irrevocable Signature over Printed Name of Irrevocable Signature over Printed Name of Assignee (if any)
Beneficiary (if any) Beneficiary (if any)
BDO Life Assurance Company, Inc.
(Formerly Generali Pilipinas Life Assurance Company, Inc.)
BDO Corporate Center, 7899 Makati Avenue, Makati City, Metro Manila, Philippines
Customer Care Hotline: (632) 8854110 | Trunk lines: (632) 8854100, 8854200 | Fax (632) 3250792