Special Power Of Attorney
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1SPECIAL POWER OF ATTORNEY
I
_______________________,
hereby
name,
appoint
and
constitute
_________________________ to be my true and lawful attorney, to act on my behalf and
in my name, to execute and perform all or any of the following acts, deeds, matters and
things, in connection with _________________________, to wit:
1. Present and submit all documents in connection with PhilPlans First Inc. (PhilPlans)
Plan No. _________________________________ (the “Plan”) in which I am identified as
the Planholder, pursuant to the requirements of PhilPlans for the processing of claims.
2. To collect on my behalf and in trust for me any and all benefits that may accrue to me
or to my designated beneficiary/ies by virtue of said Plan, if I am identified as the proper
claimant of said benefits.
HEREBY GIVING AND GRANTING unto our said attorney full powers and authority
to do and perform all and every act requisite or necessary to carry into effect the
foregoing powers, as fully to all intents and purposes as I might or could lawfully do if
personally present, with full power of substitution and revocation, and hereby ratifying
and confirming all that my said attorney or his substitute shall lawfully do or cause to be
done by virtue hereof.
IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of _________
___________, in __________________.
__________________________________
Conforme:
____________________________________
Appointee
REPUBLIC OF THE PHILIPPINES
)
_________________ CITY
) S.S.
SUBSCRIBED
AND
SWORN
to
before
me
this
_____
day
of
_________________________________ in ________________________, affiant exhibiting to
me the following proof of identity:
Doc. No. ____
Page No. ____
Book No. ____
Series of _______.
th
8
Floor, PhilPlans Corporate Center, Kalayaan Avenue, Triangle Drive, Fort Bonifacio, Taguig City
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