Application For Cash Withdrawal And Policy Loan Form (Page 2 of 3) in pdf

Application for Cash Withdrawal and Policy Loan Form

Declarations and Agreement

Note:

The undersigned hereby applies to the Company for a loan and/or borrow against Policy Cash value on the above policy and

hereby assigns to the Company, the policy and benefits now due or which may hereafter become due or be allowed by the

Company on the policy, to secure the repayment of the said loan and the interest thereon. The undersigned executing this

This part only applies to a policy

which permits the owner to apply

form certifies to the Company that no proceedings in bankruptcy or insolvency have been instituted or are pending against

for a loan or borrow against the

me. I declare that I have read and understood the relevant conditions stated below and agree to and accept the same.

policy cash value.

I/We, the undersigned, owner/s and/or irrevocable beneficiary/ies of the said policy, hereby apply for the policy loan as

indicated above subject to the relevant terms and conditions of the policy.

I/We understand and agree on behalf of myself and the Insurance/ Policyowner (”Relevant Persons”) that:

Important:

Payment of Loan is encouraged to

1. That this loan shall bear interest prescribed by the Company payable in advance from this date of next anniversary

restore the cash value and/or

date of my/our policy when the loan becomes due and repayable in accordance with the terms and conditions of

conserve intended benefits.

the policy;

2. That this loan and the interest hereinabove specified shall be paid at the Home Office of the Corporation while the

policy remains in force, and during that time the loan may be paid in full amount or installments; and that credit

will be allowed for the unearned or unexpired interest on every payment made;

3. That from the said sum borrowed shall be deducted any existing loan advances, indebtedness and other accounts

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due on said policy, and the interest on this loan;

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4. That any notice relative to this loan addressed to my/our last known post office address shall be deemed to have

been duly served;

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5. That the provisions of the said policy in relation to policy loans, not otherwise stated herein, are hereby

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incorporated in this Loan Agreement, by reference, and made a part thereof;

about the Company and your

6. That if the amount of loans or other indebtedness to the Corporation on the said policy, together with the accrued

policy. Help us ensure timely

interest thereon, shall become equal to the policy’s cash value, your failure to pay the loans and other indebtedness

delivery of our services

together with the accrued interest thereon within the period specified in the written notice thereof shall terminate

your policy and render it with no force and effect without the necessity of further notice; and

by providing us your current

That I/we further agree that this assignment of my/our rights and interest in the policy against which this policy

contact information.

loan is granted shall be binding upon me/our successors in interest or assigns even if such assignment be not

endorsed on the policy, any provisions therein to the contrary not withstanding.

Here is my updated information:

Mailing Address:

Home

Business

IMPORTANT: PLEASE DO NOT SIGN ON A BLANK FORM

_______________________________

Signed at __________________________________ this _______day of _______________________.

_______________________________

Signature over printed name of Policy Owner

_______________________________

Signature over printed name of Assignee*, if any

_______________________________

Home No.:

_______________________________

Office No.:

Signature over printed name of Irrevocable Beneficiary*, if any

_______________________________

Mobile No.:

_______________________________

Email Address:

*If there is more than 1 assignee and or irrevocable beneficiary, please use this portion in indicating their

_______________________________

respective names and signatures.

YES! I would like to receive news

from AXA via:

Mail

Mobile SMS

Personal Call

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PPH1CWPLFM2011.07

Application For Cash Withdrawal And Policy Loan Form Page 2

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