Dividend/Endo

wment Benefit
Dividend/Endowment
Authoriza
tion FForm
orm
Authorization
For Company Use Only
Pick up date: _____________
Pick up time: _____________
Scanned date: _____________

In this form, you and your refer to the policy owner, planholder, endowment beneficiary, whomever is applicable while
we, us, our and the Company refer to Sun Life of Canada (Phils), Inc. and/or Sun Life Financial Plans, Inc., both are
members of the Sun Life Financial group of companies.

General Information

Please PRINT clearly.

Use BLACK ink.

Policy Owner/Planholder /Endowment Beneficiary (Last , First , Middle )

Contact Nos.

Email Address

Life Insured (if different from Policy Owner) (Last , First , Middle )

Policy/Plan Number

Anniversary Date (mmm/dd/yyyy)

Request Details
For :

Please check the appropriate

box.

Current Dividend Option:

Dividends
as Addition to Policy*

Endowment Benefit
Dividend Accumulation

Paid in Cash

Applied to Installment/Premiums

*This option is applicable only for participating life insurance policies issued by Sun Life of Canada (Phils.), Inc.

You authorize us tto:

o:

Withdrawal of dividends (A)

and application of the
amount withdrawn (B) are
applicable for participating
life insurance policies issued
by Sun Life of Canada
(Phils.), Inc. with current
dividend options in effect
as Paid-Up Additions and
Dividend Accumulation.
For participating plans issued
by Sun Life Financial Plans,
Inc., A and B are applicable
only on plans where the
current dividend option in
effect is Dividend
Accumulation.

1. Dividends
A. Withdraw the amount of
Currency

US$

amount in words and figures

Php

B. Apply the amount of

Amount in figures

To Policy/Plan

For
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.

2. Endowment Benefit
A. Withdraw the amount of
Currency

US$

amount in words and figures

Php

B. Apply the amount of

Amount in figures

)
To Policy/Plan

For
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
Option is requested.

as Addition to Policy*

The new option will be applied to subsequent dividends.

The policyowner to complete

this portion only if a change in
Endowment Benefit Payout
Option is requested.

Dividend Accumulation**

Paid in Cash

Applied to Installment/Premiums

*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).

4. Change the Endowment Benefit Pay-out Option to

receive the amount in cheque

leave the amount on deposit with the Company

Signatures

This section must be signed by the

policyowner/planholder for
withdrawal of dividends and
change in dividend option, and by
all elected endowment beneficiaries for withdrawal of endowment
benefit.
The policyowner and all irrevocable endowment beneficiary/ies
must sign if request is for a change
in Endowment Benefit Payout.
Witness should be a Sun Life
advisor, staff, Notary Public or any
disinterested adult person.

X
Place of Signing

Date of signing (day/month/year)

Signature of Irrevocable Endowment Beneficiary

Printed Name

X
Printed Name

Signature of Witness

X
Address of Witness

*DEAF.04.10*

DEAF.04.10

Pick Up Stub

Printed Name

Signature of Policyowner/Planholder/Endowment Beneficiary

For

Dividends

Please present this stub together with:

Endowment Benefit

Policy Number

a)

Two (2) Valid IDs (SSS ID, GSIS ID, Drivers License,
Passport, NBI ID, Postal ID, Senior Citizen ID, etc.)

Policyowner

b)

Authorization to pick up the cheque if policyholder/

planholder/endowment beneficiary cannot pick up the
cheque personally.

The cheque will be ready for pick up on:

Date (day/month/year)

at

Time

New Signature Specimen

This section must be

completed if there is a
change in signature.

Please provide 2 specimens

of your new signature on
the space provided.

As proof, you are hereby presenting originals of the following IDs on which your new signature appears. Please attach
photocopies of IDs presented.

Type of ID

ID Number

Issuer

(New) Signature

(New) Signature

Expiry Date

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

Place of Signing

Date of Signing (day/month/year)

X
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.

Signature

This section should be

completed by the staff who
received the documents

Name of Receiving Staff

Please obtain identification

documents of policy owner/
planholder/endowment
beneficiary and list them
down on the space provided.

Identification Information of Policy owner/Planholder/Endowment Beneficiary

Section/Department

X
Date & Time Received

Other documents received

Scanned Date

Acknowledgment Receipt

This Section must be signed

by the recipient of the
cheque. Please indicate if you
are the Policyowner,
Endowment Beneficiary, Life
Insured, Representative or
Agent after your signature.

Cheque Number

Cheque Date (day/month/year)

Cheque Amount

Date Received

Payee (last Name, First Name, M.I.)

Signature of Policyowner/Endowment Beneficiary/Life Insured/Representative/Agent

Printed Name

X
7

Notarization

If this form will be signed

outside the Philippines,
please have the form
authenticated by the nearest
Philippine Consul in your
locality.

DEAF.03.09

SUBSCRIBED AND SWORN to before me this ___________day at _________________________________________,

Philippines, affiant having exhibited to me his/her _______________________________________________________
issued on___________________________________at___________________________________________________.
Doc. No.:
Page No.:
Book No.:
Series of

NOTARY PUBLIC