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Form Number CS-0001 LIFE INSURANCE POLICY WITHDRAWAL REQUEST FORM POLICY DETAILS Please fill in appropriately ID Type Presented and Details Policy Number Policyowner ID No. Issued on/at Valid until Address Cell Phone No. Landline No. Please ensure IDs presented are government-issued valid current primary IDs with pictures and attach clear photocopies thereof to this form. Email Address WITHDRAWAL INSTRUCTIONS Please fill in applicable fields I would like to request for the withdrawal indicated below from the above mentioned policy Currency Amount Requested Regular BEF Plus Long Term Single BEF Plus Accumulated Dividends Premium Deposit Fund Please note that any withdrawal from your policy will affect the build up of funds intended for future use e.g. dividend related features premium deposit fund payments etc.. If the Long Term Single BEF is withdrawn partially or in full before the end of the holding period the interest rate applicable from the placement date shall be adjusted to reflect penalty charges arising from the pretermination* PAYMENT INSTRUCTIONS Please choose payment instruction Apply to premium due on policy number/s in the amount of Apply to outstanding policy loan on policy number/s indicate no. amount Issue a check payable to me and I will pick up the check personally from your head office I will send my authorized representative to pick up the check Pls. ensure your authorized representative has a letter of authorization from you and a valid government-issued ID when picking up the check. Mail the check to my designated mailing address Course the check through my servicing FA/Agent Pls. give your FA/Agt a letter of authorization for presentation when claiming the check. Please credit to my account I agree that any charges imposed by the bank to effect the transfer will be deducted from the proceeds Bank Branch Account Number Please secure a proof of account document from your bank branch to ensure the proceeds are deposited properly. For joint accounts the policyowner hereby assures Generali Philippines / Generali Pilipinas Life Assurance Company Inc* that crediting into this account will relieve the company of all its obligations related to your request. SIGNATURE AUTHORIZATION Please sign over printed name Signature over Printed Name of Policyowner Date / Place of Signing I hereby attest that there are no other persons firms or corporations with an interest in the abovementioned policy aside from those expressly indicated above. I also attest that there are no bankruptcy or insolvency proceedings pending on the abovesigned policyowner. Finally I also attest that all signatories above are of legal age and have the legal capacity to sign this document. If the Long Term Single BEF is withdrawn partially or in full before the end of the holding period the interest rate applicable from the placement date shall be adjusted to reflect penalty charges arising from the pretermination* PAYMENT INSTRUCTIONS Please choose payment instruction Apply to premium due on policy number/s in the amount of Apply to outstanding policy loan on policy number/s indicate no. amount Issue a check payable to me and I will pick up the check personally from your head office I will send my authorized representative to pick up the check Pls.

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