Dividend/Endowment Benefit
Dividend/Endowment
Authorization Form
Authorization Form
For Company Use Only
Pick up date: _____________
In this form, you and your refer to the policy owner, planholder, endowment beneficiary, whomever is applicable while
Pick up time: _____________ we, us, our and the Company refer to Sun Life of Canada (Phils), Inc. and/or Sun Life Financial Plans, Inc., both are
Scanned date: _____________ members of the Sun Life Financial group of companies.
1 General Information
Please PRINT clearly. Policy Owner/Planholder /Endowment Beneficiary (Last , First , Middle ) Contact Nos. Email Address
Use BLACK ink.
Life Insured (if different from Policy Owner) (Last , First , Middle ) Policy/Plan Number Anniversary Date (mmm/dd/yyyy)
2 Request Details
Please check the appropriate For : [ ] Dividends [ ] Endowment Benefit
box.
Current Dividend Option: as Addition to Policy* Applied to Installment/Premiums Paid in Cash Dividend Accumulation
*This option is applicable only for participating life insurance policies issued by Sun Life of Canada (Phils.), Inc.
You authorize us t o:
to:
Withdrawal of dividends (A)
and application of the 1. Dividends
amount withdrawn (B) are A. Withdraw the amount of
applicable for participating Currency amount in words and figures
US$ Php ( )
life insurance policies issued
by Sun Life of Canada B. Apply the amount of
(Phils.), Inc. with current
dividend options in effect Amount in figures For To Policy/Plan
as Paid-Up Additions and Premium/Installment Due
Dividend Accumulation.
For participating plans issued Policy Advance/Interest
by Sun Life Financial Plans, Others
Inc., A and B are applicable Reminder: You understand that if you withdraw any accumulated dividends/endowment benefits, you may lose certain options
only on plans where the available under your policy /plan.
current dividend option in
effect is Dividend 2. Endowment Benefit
Accumulation. A. Withdraw the amount of
Currency US$ amount in words and figures
Php ( )
B. Apply the amount of
Amount in figures For To Policy/Plan
Premium/Installment Due
Policy Advance/Interest
Others
Reminder: You understand that if you withdraw any accumulated dividends/endowment benefits, you may lose certain options
available under your policy /plan.
3. Change Dividend Option to
Complete this portion only
if a change in Dividend as Addition to Policy* Applied to Installment/Premiums Paid in Cash Dividend Accumulation**
Option is requested. The new option will be applied to subsequent dividends.
*This option is applicable only for participating life insurance policies issued by Sun Life of Canada (Phils.), Inc.
**If this option is elected, the third paragraph of the Grace Period provision under the plan agreement issued by
Sun Life Financial Plans, Inc. will apply while for policies issued by Sun Life of Canada (Phils.), Inc., if this option is elected,
you hereby authorize us to apply any dividend credits towards any Premium Payment Default Option in effect and any
interest on outstanding policy advances (loans).
The policyowner to complete
this portion only if a change in 4. Change the Endowment Benefit Pay-out Option to
Endowment Benefit Payout
Option is requested. receive the amount in cheque leave the amount on deposit with the Company
3 Signatures
This section must be signed by the Signature of Policyowner/Planholder/Endowment Beneficiary Printed Name
policyowner/planholder for
withdrawal of dividends and X
change in dividend option, and by Place of Signing Date of signing (day/month/year)
all elected endowment beneficia-
ries for withdrawal of endowment Signature of Irrevocable Endowment Beneficiary
benefit. Printed Name
The policyowner and all irrevo- X
cable endowment beneficiary/ies Signature of Witness Printed Name
must sign if request is for a change X
in Endowment Benefit Payout.
Address of Witness
Witness should be a Sun Life
advisor, staff, Notary Public or any
disinterested adult person.
DEAF.04.10 *DEAF.04.10*
Pick Up Stub For [ ] Dividends [ ] Endowment Benefit
Policy Number
Please present this stub together with:
a) Two (2) Valid IDs (SSS ID, GSIS ID, Driver’s License, Policyowner
Passport, NBI ID, Postal ID, Senior Citizen ID, etc.)
b) Authorization to pick up the cheque if policyholder/ The cheque will be ready for pick up on:
planholder/endowment beneficiary cannot pick up the Date (day/month/year) Time
cheque personally. at
4 New Signature Specimen
This section must be As proof, you are hereby presenting originals of the following IDs on which your new signature appears. Please attach
completed if there is a photocopies of IDs presented.
change in signature.
Type of ID ID Number Issuer Expiry Date
Please provide 2 specimens (New) Signature (New) Signature
of your new signature on
the space provided. X X
I have examined the original IDs enumerated above. I have compared the attached photocopies with original documents
and hereby confirm these to be true and correct copies of the original IDs.
Signature of Witness Printed Name of Witness
X
Place of Signing Date of Signing (day/month/year)
5 For Company Use only
Please describe how existing dividends for policies issued by Sun Life of Canada (Phils.), Inc. were disposed of if Option
Change is requested.
This portion is for the use of
Client Services Department
only.
Name of Receiving Staff Signature
This section should be
completed by the staff who X
received the documents Section/Department Date & Time Received Other documents received Scanned Date
Please obtain identification Identification Information of Policy owner/Planholder/Endowment Beneficiary
documents of policy owner/
planholder/endowment
beneficiary and list them
down on the space provided.
6 Acknowledgment Receipt
This Section must be signed Cheque Number Cheque Date (day/month/year) Cheque Amount
by the recipient of the
cheque. Please indicate if you
are the Policyowner,
Payee (last Name, First Name, M.I.) Date Received
Endowment Beneficiary, Life
Insured, Representative or
Agent after your signature.
Signature of Policyowner/Endowment Beneficiary/Life Insured/Representative/Agent Printed Name
X
7 Notarization
If this form will be signed SUBSCRIBED AND SWORN to before me this ___________day at _________________________________________,
outside the Philippines, Philippines, affiant having exhibited to me his/her _______________________________________________________
please have the form issued on___________________________________at___________________________________________________.
authenticated by the nearest
Philippine Consul in your Doc. No.:
locality. Page No.:
Book No.: NOTARY PUBLIC
Series of
DEAF.03.09