Application For Cash Withdrawal And Policy Loan Form printable pdf download

*PPH1CWPLFM*

Policy Number(s)

Application for Cash Withdrawal

and Policy Loan Form

Important Notes:

1. This form is to be accomplished by the Policy Owner/Assignee in BLOCK LETTERS.

2. Please do not sign on a blank form.

FOR OFFICE USE ONLY

3. Please put a shade in the circle to indicate your choice(s).

Date Received: ____________

Type of Withdrawal

Time Received: ____________

Receiving

Cash Withdrawal as specified

Dept./Office: ______________

Policy dividend

Refund of excess payment

Policy Loan

Amount to be withdrawn

FOR DISTRIBUTOR’S USE ONLY

All balance

Partial cash withdrawal in the amount of _______________________

FE/Advisor’s code:

to be paid to me

to be applied to Policy No. ____________________________________

__________________________

as premium payment

as loan payment

others __________________

FE/Advisor’s name:

Policy Details

__________________________

FE/Advisor’s mobile number:

Full Name of Insured (Last Name, First Name, Middle Initial)

__________________________

Phone No.

Cellphone No.

Full Name of Policy Owner (Last Name, First Name, Middle Initial)

Requirements:

Photocopy of one (1) primary

current valid ID.

Phone No.

Cellphone No.

Pls. be prepared to present

your valid ID.

Full Name of Assignee

Notes:

Phone No.

Cellphone No.

Policy Owner and Assignee/

Irrevocable Beneficiary/ies (if any)

Application for Policy Loan

must submit clear photocopy of

stated identification cards that

clearly shows photo, signature and

Application for policy loan

other details and should NOT be

expired.

Maximum amount available

Policy Owner is entitled to the

Certification of Customary Signature

maximum cash value withdrawal

amount set by AXA Philippines

IMPORTANT: If signature differs between AXA file and documents submitted, please complete this form.

CERTIFICATION OF CUSTOMARY SIGNATURE

This is to certify that I am the same person who signed in the policy contract. I hereby confirm that the declarations

and information therein were given by me, and I certify that they are true and complete to the best of my knowledge.

Finally, the signature appearing on all the forms and valid ID/s are my customary signatures and for which reason

I have signed both with my customary signatures as follows:

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PPH1CWPLFM2011.07

Application For Cash Withdrawal And Policy Loan Form

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