Please provide us with your latest contact information

in order for us to update your records.

Policy Number

Policy Holder’s Name

Mobile Number

Landline Number

Email Address

Alternate Contact No.

Signature over Printed Name Date

of the Policy Holder

Email this form to customercare@manilabankerslife.com

For more information and assistance, please contact our customer service team:
(632) 810-1040 / 810-1051/ 810-1072 loc 305/306/308
(SMART) 09989641224 (GLOBE) 09178006054

I ____________________, of legal age, Filipino citizen and a resident of ________________________________ do hereby state
that; MANILA BANKERS ASSURANCE, a corporation duly organized existing under Philippine laws with office
address at the 3rd Floor VGP Center, Ayala Avenue, Makati City, is requesting for my personal data and information
for the purpose of updating my information on my insurance policy. I have been informed of my rights under R.A.
10173 and I hereby freely, voluntarily, willfully, and intelligently give my consent to MANILA BANKERS ASSURANCE to
gather, collect, hold, process, and use my personal data and information for the purpose stated above.

Signature Over Printed Name

3rd Floor VGP Center, Makati City customercare@manilabankerslife.com www.manilabankerslife.com