THE INSULAR ASSCE. CO. Ltd. 6781 Ayala, Makati City         RE: POLICY NO._______________ DATE: _________________             TO WHOM IT MAY CONCERN:             I / WE WOULD LIKE TO WITHDRAW THE ACCUMULATED DIVIDENDS / CASH SURRENDER VALUE OF PAID-UP ADDITIONAL INSURANCE PURCHASED BY MY / OUR DIVIDENDS ON THE ABOVE-NUMBERED POLICY / IES.         THANK YOU.           _____________________________ IRREVOCABLE BENEFICIARY (Signature over Printed name) ______________________________ POLICY OWNER (Signature over Printed name)

(Print Form)

After printing this form, please affix your signature and include all the necessary requirements
(see Policy Servicing Requirements)
then mail or submit to :

Insular Life Corporate Centre
Insular Life Drive
Filinvest Corporate City
Alabang, Muntinlupa City

ATTN: Mr. Jose A. Padilla