Request Form for Refund

1. General Information

The "Recipient" could either be the policyowner, insured, claimant or any person designated as payee.
Name

First NameMiddle NameLast Name
Policy Number(s)
Amount
2. Details of Request
Mark "A" if request is for deposit to local bank. Mark "B" if request is for currency conversion and to deposit through cross border (overseas) transfer for clients living overseas.
Please mark your preferred currency

Other, Please specify
and credited to your bank account through cross border (overseas) transfer with the following information
Account Name
Account Number
Name of Bank
Address of Bank
Routing or Serial Number (applicable for letter B only)
Swift Code Number (applicable for letter B only)
Subject to avalability of the currency in the bank Notes: 1.Please ensure that you provide the correct account information The Company will not be liable if the remittance is credited to an erroneous bank account number 2. Submit any of the following proofs of bank account a Bank Statement of Account b. Certificate of Bank Deposit

c First Page of the Bank Passbook d. Check

The bank account number and the account name must appear on one (1) page and should be readable and clear. Please mask account details and names of other account holders, if any. The Company may require presentation of additional documents to validate submissions

By signing you confirm and agree that 1. The above details are correct and that you declare under the penalty of fraud that you are the owner of the stated bank account number; 2. You will shoulder any bank fees and charges related to the deposit to your bank account; 3. Deposit of the amount through your designated bank account number or account name fully releases and discharges the Company from any claims or liabilities related thereto; 4. You agree to indemnify and hold the Company free and harmless from and against any and all claims, losses, including opportunity loss, damages, or expenses as a result of your credit to account and/or currency conversion request, including any misrepresentation as to the owner of the bank account, and/or failure of your bank or its intermediary to honor the transaction; and 5. You agree to the processing of your personal and sensitive personal information for the additional purpose of implementing your equest/instructions herein in accordance with Sun Life's Privacy Policy available at https://apps.sunlife.com.ph/privacy, reaffirm your consent tothe processing of your personal data as recorded in your most recent insurance application form, and acknowledge that such consent continues to be in full force and effect.

Signature over Printed Name of Recipient x
3. Signatures

By signing, you confirm and agree that:
Signature
Date of Signing (month/day/year)

MonthDayYear
Date
Address
Contact Number(s)
Conforme (Signature over Printed Name of Policy Owner - if not the Recipient)
Date of Signing (month/day/year)

MonthDayYear
Date
To credit the premium refund to the client’s bank account, kindly submit any of the following. a.) Bank Statement of Account b.) Certificate of Bank Deposit c.) First Page of Bank Passbook d.) Check copy e.) ATM Card Copy (only acceptable if complete account number is reflected)

Cancelof
An Online Form by Ma. Chona Hao.
Should be Empty:

1. General Information

2. Details of Request

3. Signatures