Policy Surrender/full Withdrawal Application Form (Page 2 of 5) in pdf

Policy Surrender/Full Withdrawal Application Form

Certification of Customary Signature

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We would like to serve you

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

better and keep you abreast

with news and information

CERTIFICATION OF CUSTOMARY SIGNATURE

about the Company and your

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

policy. Help us ensure timely

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

delivery of our services

by providing us your current

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

contact information.

I have signed both with my customary signatures as follows:

Here is my updated information:

Mailing Address:

Home

Business

_______________________________

Declaration

_______________________________

I/We HEREBY DECLARE AND AGREE ON BEHALF OF MYSELF/ OURSELVES AND THE INSURED/POLICYOWNER

_______________________________

(”RELEVANT PERSONS”) that:

_______________________________

(1) The application/s as indicated above is/are based on my/our own judgment and I/we did not rely on any

_______________________________

advice provided by the Advisor/ FE.

Home No.:

(2) All information in the application/s whether or not written by my/our hand/s is/are to the best of my/our

knowledge and belief complete and true;

_______________________________

(3) Any personal data of the Relevant Persons collected or held by the Company (whether contained in the

Office No.:

application/s or otherwise), may be used in connection with matching for whatever purpose with such other

_______________________________

personal data and/or may be used, stored, disclosed, transferred (whether within or outside the Philippines)

Mobile No.:

to such persons as the Company may consider necessary including without limitation any of its affiliated

_______________________________

companies, or any individuals/ organizations associated with the Company:

Email Address:

(i)

to process and deal with the application/s

_______________________________

(ii) to provide all services related to the application/s and promote and improve services by the

YES! I would like to receive news

Company and its affiliated companies

from AXA via:

(iii) to communicate with the Relevant Persons for any purpose and/or comply with the laws of any

Mail

applicable jurisdiction

Mobile SMS

Personal Call

(4) If the Relevant Persons fail to provide any information requested in the application, it may result in the

Company’s inability to process and to deal with the application/s;

(5) I/We have the full authority from and consent of the Relevant Persons to make the above declarations

and agreements. The Relevant Persons have the right to request, access to and correct any of the personal

data held by the Company concerning the Relevant Persons. I/We understand that any request may be

made in writing and addressed to the Head of the Channel Services Department at AXA Philippines

Head Office.

I/We, the undersigned owner/s and/or irrevocable beneficiaries of the said policy, hereby apply for Policy Surrender

of the policy in exchange for its Cash Value/ Full withdrawal of the policy in exchange for its acciunt value according

to the terms and conditions of the policy. I/We hereby declare that I/ we am/are legally entitled to the Cash Value

under the policy which has not been assigned or transferred to any other party, and that no proceedings in

bankruptcy or insolvency have been instituted or are pending against me/us. The liability of the Company in

connection with the policy is as of the date of this application limited to the Cash Value. Upon payment of the Cash

Value, the Company shall be discharged from all liabilities under the above policy.

I/We understand that:

(1) any premium paid will not be refunded;

(2) subject to the Deferment and Limitation provision of the above policy, the Cash Value will normally be

payable within such period as statedin the policy after the receipt of my/our valid written application and

original policy contract by AXA Philippines Head Office.

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PPH1PSFWAF2011.07

Policy Surrender/full Withdrawal Application Form Page 2

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