Tick the box beside the request that you

are filing. For CARE/EAB, Pre-Maturity

Benefit or Lumpsum, select Others and
write the request in the space provided.
Should be the same as the info in the
Benefit Settlement Form.
Name of Planholder Nationality
Address

Indicate Pension, Education or Memorial Plan Number or Agreement Number

appearing in the Policy Contract or
Certificate of Full Payment.

Amount in figures

Amount in words

Verify your account if it’s Savings or

Checking/Current account and write it in
the space provided. Confirm with your
bank that it is not a “Cash-Deposit-Only”
account.

Should be the same as the account

number appearing in the submitted
bank document

Should be the same as the Bank Name

appearing in the submitted bank
document

Indicate the date this document was

accomplished

Print complete name and sign above it

Contact info of the Planholder