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Specimen Signature Form 10042019 FINAL

This document is a specimen signature form for a life insurance policy. It provides fields for the policy owner and life insured to provide old and new signature specimens. It also includes fields for an irrevocable beneficiary's signatures. The form notes that it should be filled out in capital letters using black ink and indicates what should be done if a field is not applicable. It also provides contact information for the insurance company and a statement giving the company permission to share policyholder information for various purposes like offering other products or as required by law.

Uploaded by

ANGELO APORTADERA
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
2K views

Specimen Signature Form 10042019 FINAL

This document is a specimen signature form for a life insurance policy. It provides fields for the policy owner and life insured to provide old and new signature specimens. It also includes fields for an irrevocable beneficiary's signatures. The form notes that it should be filled out in capital letters using black ink and indicates what should be done if a field is not applicable. It also provides contact information for the insurance company and a statement giving the company permission to share policyholder information for various purposes like offering other products or as required by law.

Uploaded by

ANGELO APORTADERA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Specimen signature form

PRU LIFE INSURANCE CORPORATION OF U.K.


(May be omitted if beneficiary designation is revocable) 9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
1634 Taguig City, Philippines
REMINDERS: Customer helpdesk: (632) 8683 9000, (632) 8884 8484, (632) 8887 LIFE
Please use CAPITAL LETTERS and black ink. within Metro Manila, 1 800 10 PRULINK for domestic toll-free
Tick the appropriate box to indicate your choice. Email: contact.us@prulifeuk.com.ph Website: www. prulifeuk.com.ph
Please do not sign on a blank form.
If not applicable, put “N/A” in all empty fields.

(For office use only) Date received: Time: am/pm Received by/Deparment:

Name of Life Insured


( SURNAME, GIVEN NAME, MIDDLE NAME. ) Birthdate (mm/dd/yyyy)

Life Insured
Name of Policyowner
( SURNAME, GIVEN NAME, MIDDLE NAME. ) Policy number

Please recognize any/all of the following signature/s for any transactions under the policy number specified above:

Life Insured
Old signature New signature

1. _______________________________________________
_ 1. _______________________________________________
_

2. _______________________________________________
_ 2. _______________________________________________
_

3. _______________________________________________
_ 3. _______________________________________________
_

Policy Owner

Old signature New signature

1. _______________________________________________
_ 1. _______________________________________________
_

2. _______________________________________________
_ 2. _______________________________________________
_

3. _______________________________________________
_ 3. _______________________________________________
_

Irrevocable beneficiary

Old signature New signature

1. _______________________________________________
_ 1. _______________________________________________
_

2. _______________________________________________
_ 2. _______________________________________________
_

3. _______________________________________________
_ 3. _______________________________________________
_

Pru Life UK may transfer, disclose or communicate any information relating to my/our policy/ies to any of the branches, subsidiaries, affiliates, agents and representatives of Pru Life UK, Prudential Corporation Asia,
Prudential plc and third parties selected by any of them, to be used for the purpose of offering, soliciting or providing any product or service which may be of interest or benefit to me/us or related to my/our policy/ies or
for any other purpose such as data processing and storage, anti-money laundering monitoring, review and reporting. In addition, Pru Life UK, its offices, branches, subsidiaries, affiliates, agents and representatives
may transfer, disclose and use any such information as may be required by law or regulation.

Signature over printed name

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