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

Application for Cash Withdrawal and Policy Loan Form

Payment Instructions

(Choose 1 of 3 option)

FUND TRANSFER (Applicable for both Peso and Dollar policies). Please submit any of the following:

Bank Certificate (Note: include Bank’s Swift code for non-Metrobank account)

Request for Direct Credit to Bank Account form (Note: Please complete the Request for Direct Credit to Bank Account Form below)

CASH WITHDRAWAL (Applicable for Dollar policies and can be withdrawn at any Metrobank Branches only)

(Note: Please complete the Specimen Signature Form below)

CHECK PAYMENT

(Applicable for both Peso and Dollar policies), please choose below your preferred mode of check delivery.

I will pick up the Check at

Thru my Personal Representative

Head office

AXA Branch:

Name:

Thru my Billing Address:(House No./Street) (Brgy) (City) (Province) (Zipcode)

IMPORTANT: If payment instruction is via FUND TRANSFER, please complete

IMPORTANT: If payment instruction is via DOLLAR CASH withdrawal,

below form and have it verified by Bank Branch Head/BOO.

please complete this form.

REQUEST FOR DIRECT CREDIT TO BANK ACCOUNT

SPECIMEN SIGNATURE FOR CASH WITHDRAWALS

Policy No.:

Account type:

Policy No.:

Peso account

Dollar account

Bank Name:

Name of the Policy Owner:

Metrobank

Others: ___________________________________________

Branch Name:

Swift Code (for Non-Metrobank)

Preferred Metrobank Branch:

Account Number of payee:

Branch Tel. No.:

Branch Fax No.:

Account Name of payee:

Declarations and Agreements:

Specimen Signatures:

I declare that the proceeds of this application/policy once deposited to the account aforementioned

shall be equivalent to payment to me directly of the same and I shall render AXA Philippines, its

successors-in-interests and assigns, including its directors, officers, employees and agents, free

and harmless from any further claim, demand or action whatsoever, which in law or equity I ever had,

now have, or which I, my successors and assigns hereafter may have under this said application/policy.

I declare that in the event the account aforementioned is owned by person other than me, the

account owner is my relative and that I had sought his/her consent to use his/her account to

facilitate the payment to me of the proceeds of this application.

I understand that should the proceeds be credited to a non-Metrobank account, corresponding fees

shall be charged to my account.

I/We, the undersigned, also take full responsibility in the accuracy of the account name and number

indicated above. Should there be any error(s) in the information, I/We understand that this will

result to delays in the crediting of the policy proceeds and I/We shall bear the consequences.

Before signing this declaration and agreement, I have read and understood all declarations which

are hereby given and made willingly and voluntarily and with full knowledge of my rights under

the law.”

__________________________________________

Signature Over Printed Name of the Policy Owner

___________________________

Relationship of claimant to Account Owner

Signature Over Printed Name

of the Account Owner

(If claimant is different from Account Owner)

Account Name and No. verified true and correct by:

Note: Third Party Account

Owner is only limited to:

___________________________

Signature Over Printed Name

1. Spouse

3. Parents

of BOO/ Branch Head

2. Children

4. Siblings

of 3

PPH1CWPLFM2011.07

Application For Cash Withdrawal And Policy Loan Form Page 3

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