rns Death Claim Form \We understand that this claim is important to you. In order for us to speed up the process, please: 1) complete this form. (2) prepare the required documents: and, (3) submit the completed form and required documents t@ your agent or Philam Life Branch. Being prepared might reduce some of the confusion and could help speed up the process. We want yaur claim experience fo be a positive one. To ease your claim procedures, use this checilst to identify the relevant documents required to be suomittes. ‘Addiional requirements may be required ifthe claim falls within the two-year contestabilly period ofthe policy. (Eases [outs accompished Death clin Statement Form Original copy of NSO death certificate of the deceased. if death occurred abroad, death certificate LL! must be authenticated by the Philippine embassy/consulate in the place of death [1 one «vale identification card (with picture and signature) ofthe claimant/s ADDITIONAL REQUIREMENTS | Marriage Contract - it spouse is the beneficiary Er] pote investigation Report death is caused by an accident Joint-Affidavit of Two Disinterested Persons - if there are discrepancies in the names of insured or LL! beneficiaries [Faith conieateofrinorbenefcir child isthe beneficiary FF] cardia bone of ot ot hese of ric benticy bere execs Fr 950,500 Tr anid of ep ies “erm wt Tal asso acon sine ceca cas [] beath certiticate of deceased beneticiary/ies ee eee Warring fing ol fauddent lim penaed bylaw: ‘Section 251 ofthe Inuance Code, az amended. impores a fine not exceeding twice the amount claemed and/or imprizonment {af two 2) years or both tthe ccertion of the cour, to any person who presents oF causes fo be presen any fraudulent lam forthe payment of alos under a contract of insurance, ana Who Frauduletly prepares makes or sloschbes any WrENS with nent fo present or use the same, orto alow ito be presented In support of any clam.Date: ¢mrv/éeiyyvy) Policy Number Indicate policy numbers scrisain. Number where this claim may also be applicable Certificate Number, Tpism.so a iled bythe lainant. Please donot sign on @ blank for No tees, commizcion or charges of whatever nature are payable fo Agents Or Employees of the Company fi respect of this Gaim. Deceased’s Name in Full: (Last Name, First Name, Middle Nome) Date of Birth: (rmildyyy) Place of Birth: Nt ges ur Claimant's Name in Full (Last Name, First Name, Middle Name) Claimant's Maiden Name if married Date of Birth: (mmissivyy) Relationship to the deceased: ‘Mobile Number: (091% -7000000) (Where we wil send status end undtes of your elim) Occ coe senamePoteyupsaes via: [Jemat [Jot [Jerson Is agent on record (the agent appearing in the insurance application form) authorized to pick-up the check? Che [x0 If yes, a duly written authorization is required, and only forthe agent on record, TNs seat comers etc Are you a US cltizen? If yes, please submit @ W-8 form hs No_ 1 lace of birth s the US, please submit W-2 es 10 if adress isin the US, please submit W8 SEN. If to be credited to 8 US bank account please submit WS BEN, | ieee oo Track your Claim Status Once your claims ragistered, you ‘nl be updated through SMS. you have any query on your claim, please reach us at: dy TALK TO US NOW (02) 528-2000 ><] EMAIL US PHILAMLIFE@AIACOM Philam Life is committed to making ‘your insurance claim pracess as asy and stress-free as possible. ‘Thank you for insuring with us. We are always glad to be of service Philam Life Head Office 15-18th F Net Lima Bldg. 5th Avenue comer 26th St. Bonifacio Global City, Taguig, Metro Manila, Philippines 1634Ne Ly 25h) tia PHAM LIFE 1p: cena YEN Credit to my Bank Account (NOTE the account you spediy ie with a banc other than BPI er BOO, applicable charges may be decicted from the proceed) Bank: Branch: Tipectaconne LC] savings []checking Anat On [Tooter [7] peso ‘Account Name: eomwerse: TT OCOLOLO [Claim at any BPI/ BPI Family Branch LL crore re cpton.you are azhorang the Company tous he mobile hens number sae ove fos communaten pertain ote tanacton) | certify that Lam the owner/insured/beneficiary/assionee of the policy ies) with Philam Life and that |am the account owner of the abave designated Gank aecount.| certify to the accuracy and truthfulness of the bank information which | provided and | am aware that any discrepancy may cause delay n the craciting of the Brocaads to my account, in the evant of changes to this information | shall inform Pham Lifein writing, Further, | ‘gree that the crediting by Philam Life of the emaunt that may be due to me to the above bank account which Fiesignated shal forever felease and discharge Philam Life from all actions, claims. and demands relating to my claim against the policy (les) with Philar Life Le ee Claimants Signature Date PlaceAh ae Td 1. thereby crity that at information including all of my personally dentable and senstve information which have ‘veluntaly provided to The Phiippine Armeican life and General Insurance Company, through this Form and related Ldocuman:s true and coractta the bes af my wn knowledge and Dale 2. further agree to third party processors required by the Compary in ore to maintain qualty and delver efficent and fective services rlavant to my claim and other services| have avaied of. Saree and authorize the Company to collect, record, organize, store. uodate transfer, se for purposes of my cai and such other services related thereto, and for ether sencesineluding mentoring and/or audit, and to process as necessary, any of my personal data relative to this claim or any personal data which the Company may have or any updates thereof under the folowne orcumstances 2. To prowie the claim and other services | requested as state inthis For bo. To acknowledge and agree that macica information vill be uploaded to @ Macical databace sccessicle tollfe insurance companies win will ave lented access 0 sald medica information inorder to protect my night to prvacy in accorsanes with lay understand thats e>py of Insurance Crevlar Lotter No. 2016-54 is accossole through the Insurance Commission website at wn ngurance ov ph ‘6. To disclose my information tothe Comeany’s afilations (including but nt limited to any ofits subsideres/afiiates in the Asia Pacic Region) ts Brokers, Agents and thei employees and {tal and to accredited/afated thrd paris orindapendect/non affliated tnrd parties whether local foreign. inthis regard the Company employs security systems designed fo protect ry information against unauthorized access. , Inorder to improve the quality of sarvice the Company pcovides, the Company may uso such information it the design and communication of ts customer (including beneficiaries and claimants) pcogrems, marketing campaigns and effers @. Toalow the foregoing Consent to remain val from its execution and until 10 years after the termination Cf my poly, ora such te that | submit tothe Company 3 written revocation or cancalaion of such Consent whichever \s earlier. agree that my personal cata willbe deleted or dastroyed ater ths pence 4 thereby acknowledge and warrant that have acquired the consent of al partes pertinent ta this transaction to close thelr 'nformaton fer the proper administration and provision of services requested from this transaction. Inereby hala free and harmless and undertake to indemny the Company fer any cernpaint, sit or damages and the ike hich any party may fe lor claim against the Compary in relation to tis Acknowledgement and warranty. 5. thereby authorize Pham Life or ary of its authorized representative to secure whatever Information er recor rom any employer, physician, hospital or clinic, other mesially related fcity, anc ary orgerization or persons whe have records and/or nosledge with regard to te nas, sickness or inj Ofte Insured as descrbadin ts Claim Statement Form. This authorization sn connection with my claim en the insurance adic (is) issued bythe Company onthe ite ofthe lnsued. | undarstand that fal to release such omeloymant or medical records may delay the processing and/or deny ery clam for insurance proceeds. RES RCRA PPS eset ee Claimants Name in Full: (Last amo, Fest Name, Mille Narne) ee Soe, ‘Claimant's Signature Date Place@ POLICY OWNER’S CONSENT AND WAIVER FORM PHIEAM LIFE ‘The Company and its affliates (‘the Group") are subjact to and required to or has agreed to, ‘comply with certain legal, regulatory andlor other requirements in respect of Anti-Money Laundering and Counter Terrorist Financing (‘AML’), Know Your Client (‘KYC’) and/or as set out pursuant to the US Foreign Account Tax Compliance Act (the Reporting Requirements”) as well 23s other laws and regulations which now or which may in the future come into effect. AS such, Uwe provide our express consent that the Company shall have the right to provide such personal data and information to any governmental authorities, regulatory bodies andlor any other person(s), both local and foreign, in respect of the Reporting Requirements including the United States Intemal Revenue Service. liwe understand that such disclosures may involve the cross border transfer of personal data outside the jurisdiction and that such disclosures may be with respect to i) the personal data of the Owner, the Contingent Owner, the Insured, and the Beneficiaries (the Parties’), or any of them; i) any information relating to this Policy; and ii) any information relating to any other policies held by the Parties or any of them. (We understand that the Company will not be able to sell any insurance product to me/us and provide any service if Uwe refuse to give the said express consent. 2. Account Holders who have or may have US Indicia ‘The below paragraph applies only to (i) US persons for US federal income tax purposes; or (i) If your tax status changes and you become US Person; or (il) You or Beneficiaries in connection with this Policy have indicated through information provided to us that you or such beneficiary may be in fact a US person for US federal income tax purposes (including for example a US address, a US telephone number, a TIN, etc.) The term “US Indiciat” as used below refers to any tne of the three circumstances described in (i) o (ill) above. In the event you have US Incicia and fail after request to provide such information, consent, and or assistance as the Company may from time to time reasonably require to allow it to comply with its contractual, legal andjor regulatory obligations under the United States Foreign Account Tex Compliance Act, including any required reporting to the Intemal Revenue Service of information relating to you or Beneficiaries in connection with this Policy, the Company reserves the right and shall be entitled to cancel this Policy (subject to Sections 48 and 233(b) of the Insurance Code) and return the higher of : a) all paid premiums, or b) the Cash Value or Account \Value of this Policy, in consideration of such termination, 3. (We hereby declare and agree that, by purchasing this Policy and signing below, IWe represent ‘nat le are not a US person" for US federal income tax purposes and that Ive are not acting for, or on behalf of, US person. We understand that the Company believing this statement to be true, will rely on it and act on it. Inthe event this statement i false, the Company reserves the ‘ight and shall be ented to cancel this Policy (subject to Sections 48 and 233 (b) of the Insurance Code) and return to melus the higher of :a) al paid premiums, or b) the Cash Value or ‘Account Value of this Policy, in consideration of such termination. If myfour tax status changes and Me become a US Person, we must notify the Company within 30 days. (This clause is not applicable to US Citizens or residents who must complete IRS Form W-9). A false statement or misrepresentation of tax status by a US person could lead to penalties under US law. Place Signed ate Signed (MI DDI YYYY) Policy Owner's Signature over Printed Name Policy Number (QR-CGC-POCW | REVISION 1 / APRIL 2014 PHILAM LIFE CUSTOMER CONFIDENTIALDear Valued Client, "Your tust and confidence is important to us, To ensure that Philam Life remains a tustworthy partner in your joumey foward fancalsecury ‘2nd prosper, we are making every effet fo comply fly wih tho existing laws and regulation thal govern Us. + Incomptance wit the Creat information System Act. please be informed that should you have any loan or credit fait with us, Phila Life is manded to share your basic credit dea including elated updates! corrections o the Creat information Corporation (CIC) and other erties authorized under the law, even withou your consent. ‘= In.complianco with RA-10173 algo known as the Philppine Dala Privacy Act of 2012, whose implementing Rules and Regulations ‘ook effect on Soptembor 9, 2016, Pilam Lifeie sonding you his ltor to updete you and eecure your consent Please send back the diy signed. form either through your Financial Advisor, a Philem Life branch near you, or a scanned copy vie ema ‘oh phlemorvecy@ala.com. ‘Should you have questions or concerns about the Data Privacy consent form, please cll 628-2000 or email us at oi hilamovivacy@ui. com, FFor more information on how Phim Life protect ts dat, you may vst our Privacy Statoment at wnw.pnlamlfe. com or ie thi ink to your ‘browser: hiip/vww phiamile canvenindexprivacr-sialement. him. Sincerely yous, Priam tite DATA PRIVACY CONSENT ‘In compliance withthe Data Pivacy Act (OPA) of 2012, and its Implementing Rules and Regulations (RR) elective since September 8, 206, {allow The Philippine American Life and General Insurance Company (Pilam Lie) to provide me certain serves Geclared in relation tothe Insurance potcylies | purchased, ‘As such, | agree and authorize Pilam Life Company to 1. Continue to use my and my polis’ information to process insurance services and administer the benefis as stated in my policy is). 2. Retain my information fr period of seven year from the date of termination of my pobcy, oat such me tat | submit to Pham Life a vt cancellation of this consent, whichever is eae. I agree that my information wil be deletedicestoyed after this pero 3. Retain my information in the Medical information Database shared with other ie insurance companies in accorcance with the insurance Regulation, 4. Share my information to aftates and necessary tid partos for any logiimate business purpose. | am assured that security systems are ‘employed to protect my informatio. 5. Inform me offutue customer campaigns and base is offer using the personal information | shared withthe company. algo acknowledge and warrant tht Ihave acquire the consent rom al partes relevant is consent andhold ree and harmless andindemnify Phila Life om any complaint, sul, or damagos whien eny party may fe or lam inelavon tomy consent Signed this_day of. 20___at iy. Insured Signature over Printed Name Policy Ouner Signature over Peed Name Poley Numbers: ‘Should you have questions or concems about this consent form, please call $28-2000 or emal us at oi hismprivacu@ais com, For mor information on how Phila Life protects ts data, you may vst our Privacy Statement at wen philamifacom or type this link to your browser hio/vuiw philamife com envindex/ovacy-staernent hi MARKETING CONSENT Kindly check () aporopite box neat your consent. YES, | alow Pam Lie and thd pay agent ex. Fhancial Advisor to use my persona float frre customer campsigne NO, [do notalow Pilar Life and t's third party agents (ex. Financial Advisor to use my personal information fr future customer campaigns QR-CGCO-DPI/REVISION 1/ OCTOBER 2017