1 Bplac Citi Cash Surrender Form p1 4 CC Copy5 6 21

CASH SURRENDER FORM
Policy Number
Date (mm/dd/yyyy)
CFSI Officer Code
GENERAL REQUIREMENTS
• Policy Owner’s Identification Cards
• Irrevocable Beneficiary's Identification Cards
Please see additional requirements below for special circumstances:

• If Policy Owner is not present, please present a valid ID of the representative authorized to receive the
surrender proceeds on behalf of the Policy Owner residing in the Philippines
• If Policy Owner is abroad, please submit a current Special Power of Attorney duly authenticated by the
Philippine Consul. If this cannot be obtained, proceeds may be deposited to the Policy Owner’s local bank
account subject to authorization letter addressed to the bank, indicating bank details.
• If with minor irrevocable beneficiary, the minor's guardian shall submit Affidavit of Legal Guardianship and sign
if the irrevocable beneficiary's share does not exceed Php500,000.00 (or its US Dollar equivalent). If the share
exceeds Php500,000.00 (or its US Dollar equivalent), this application must be accompanied by letters of
Guardianship and a Court Order, authorizing the surrender of the Policy.
• If the Policy Owner or Assignee is a corporation, an officer of the corporation must sign for the corporation on
the disbursement form, and this must be accompanied by a Corporate Secretary’s Certificate and Board
Resolution authorizing the withdrawal on the policy and giving the executing officer authority to sign this
request on behalf of the corporation.
WHAT YOU SHOULD KNOW ABOUT THE SURRENDER OF YOUR POLICY

An insurance policy is intended to meet your long term protection and financial needs. In surrendering your Policy, you
will inevitably lose its valuable benefits and you may not be able to obtain a similar level of protection at the same terms
in the future. Replacing your Policy with another policy, could result in higher premiums and loss of specific features or
protection due to changes in age and/or health conditions. You may incur new charges and the periods under the
"incontestability" and "suicide" provisions may start anew under the new policy.
You have several options to consider aside from surrendering your policy:
1) Apply for a Policy Loan or an Automatic Premium Loan to keep your policy Inforce.
2) Convert your Policy to Reduced Paid Up Insurance or Extended Term Insurance.
3) Exercise a Fund Switch, or Partial Withdrawal of Investment Funds.
ANTI-FRAUD WARNING
Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or
imprisonment of two (2) years, or both, at the discretion of the court, to any person who presents or causes to be
presented any fraudulent claim under a contract of insurance, and who fraudulently prepares, makes or subscribes
any writing with intent to present or use the same, or to allow it to be presented in support of any claim.
QR-XXXX-XXXX / REVISION 0 / MAY 2021 BPLAC CUSTOMER CONFIDENTIAL
Talk to us Send us an email Contact our CFSI Officer

Customer Service Hotlines: (02) 8528-5480; For inquiries and feedback: or your Insurance Specialist
(02) 8528-5477 BPLACcustomerservice@aia.com
1
CASH SURRENDER FORM
NOTE: Fill out with block letters. Put X on the tick boxes representing options.
PART I - CONTACT INFORMATION UPDATE
I agree to update my contact information record with BPLAC based on the details in this section.
Policy Owner’s Name in Full:
Last Name First Name Middle Name
Telephone: Residence Office Mobile Phone:
(044) XXXX-XXXX 09XX-XXXXXXX
E-Mail Address:
Residential Address:
House/Building No., Street Name, Barangay
District City / Municipality Province Country Zip Code
Business / Employer Address:
House/Building No., Street Name, Barangay
District City / Municipality Province Country Zip Code
Date of Birth (mm/dd/yyyy): Place of Birth: Nationality:
Sex (defined as gender at the TIME OF BIRTH) Gender (defined as gender at the TIME OF APPLICATION)
Male Male
Female Female
Occupation and Name of Employer (if self employed, the

nature of the self employment/business activity):
Type of ID: ID Number:

2
CASH SURRENDER FORM
PART II - REQUESTED TRANSACTION
Final Maturity Full Redemption (for VUL)

Surrender Policy Cancellation within Cooling-Off Period (for Policy)
Surrender Rider with cash value Cancellation within Cooling-Off Period (Rider)
Rider: Rider:
Indicate reason for Surrendering/Full Redemption/Cancellation: This is a REQUIRED field:
PART III - PAY-OUT OPTIONS

APPLICABLE TO VUL/ULP FUNDS ONLY:
Requests received and processed by the company on or before 2PM on a banking day will follow same-day pricing. For requests received
and processed beyond cut-off, the pricing for the next banking day will be applied.
Credit to my Bank Account (NOTE: Applicable bank charges may be deducted from the proceeds)
Type of Account: Savings Account Denomination: Peso
Checking Dollar
Bank Branch
Account Name Account Number
Claim at any BPI / BPI Family Savings Bank Branch (NOTE: Applicable bank charges may be deducted from the proceeds)
I certify that I am a Policy Owner of BPLAC and that I am the owner of the aforementioned bank account number
and mobile number and that I can be reached through the mailing address declared in this application. I
acknowledge that the payment by BPLAC of the proceeds of this application through the channel I have
designated above, shall release and forever discharge BPLAC from all actions, claims and demands on all
matters involving the said benefit or amount. Further, I certify the correctness and accuracy of the above
information I provided BPLAC and I understand that any discrepancy may cause delay in the disbursement of
the proceeds.

3
CASH SURRENDER FORM
PART IV - SIGNATURE
PLEASE DO NOT SIGN ON A BLANK FORM

In consideration of this policy's cash surrender/account value, I/we hereby release and surrender all rights, title,
and interest in this Policy unto the BPLAC and agree to indemnify and protect said Company from all claims and
demands under this policy and from all losses, costs, and expenses incident to defending itself against such
claims and demands. The liability of BPLAC which issued this contract is fixed and limited to such cash
surrender/account value and any credits, and upon its payment, shall be completely discharged. It is expressly
warranted that no other person, partnership or corporation has any interest whatsoever in said Policy and that no
insolvency or bankruptcy proceedings are pending for or against the undersigned.
Place Signed Town/City Country

Date Signed
mm/dd/yyyy
Owner’s Signature over Printed Name Irrevocable Beneficiary
Assignee CFSI Officer / Witness
OTHER REQUESTS AND SPECIAL INSTRUCTIONS:
TO BE FILLED BY BPLAC PERSONNEL:

If witnessed by a CFSI Officer, indicate if: Original Reinstating Assisting/Servicing/Transferred
CFSI Officer’s Name
Last Name First Name Middle Name
CFSI Officer Code: Signature
Received by Branch/Office Date (mm/dd/yyyy) Documents submitted together

with this application:
Processed by Branch/Office Date (mm/dd/yyyy)
Approved by Branch/Office Date (mm/dd/yyyy)
NOTES:


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CASH SURRENDER FORM

CFSI Officer Code

Please see additional requirements below for special circumstances:

WHAT YOU SHOULD KNOW ABOUT THE SURRENDER OF YOUR POLICY

QR-XXXX-XXXX / REVISION 0 / MAY 2021 BPLAC CUSTOMER CONFIDENTIAL

Talk to us Send us an email Contact our CFSI Officer

PART I - CONTACT INFORMATION UPDATE

Policy Owner’s Name in Full:

Last Name First Name Middle Name

Telephone: Residence Office Mobile Phone:

(044) XXXX-XXXX 09XX-XXXXXXX

House/Building No., Street Name, Barangay

District City / Municipality Province Country Zip Code

Business / Employer Address:

House/Building No., Street Name, Barangay

District City / Municipality Province Country Zip Code

Date of Birth (mm/dd/yyyy): Place of Birth: Nationality:

Occupation and Name of Employer (if self employed, the

Type of ID: ID Number:

QR-XXXX-XXXX / REVISION 0 / MAY 2021 BPLAC CUSTOMER CONFIDENTIAL

Talk to us Send us an email Contact our CFSI Officer

PART II - REQUESTED TRANSACTION

Final Maturity Full Redemption (for VUL)

Indicate reason for Surrendering/Full Redemption/Cancellation: This is a REQUIRED field:

PART III - PAY-OUT OPTIONS

Account Name Account Number

QR-XXXX-XXXX / REVISION 0 / MAY 2021 BPLAC CUSTOMER CONFIDENTIAL

Talk to us Send us an email Contact our CFSI Officer

PLEASE DO NOT SIGN ON A BLANK FORM

Place Signed Town/City Country

Owner’s Signature over Printed Name Irrevocable Beneficiary

Assignee CFSI Officer / Witness

OTHER REQUESTS AND SPECIAL INSTRUCTIONS:

TO BE FILLED BY BPLAC PERSONNEL:

CFSI Officer’s Name

Last Name First Name Middle Name

CFSI Officer Code: Signature

Received by Branch/Office Date (mm/dd/yyyy) Documents submitted together

Processed by Branch/Office Date (mm/dd/yyyy)

Approved by Branch/Office Date (mm/dd/yyyy)

QR-XXXX-XXXX / REVISION 0 / MAY 2021 BPLAC CUSTOMER CONFIDENTIAL

Talk to us Send us an email Contact our CFSI Officer

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