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POL_ADMIN03408071 Notice of Cancellation Date : ____________________ To : COCOLIFEPolicy Service Department Cocolife Building 6674 Ayala Avenue, Makati City Re : VL Policy No. ___________________ I wish to cancel my variable life insurance coverage, please refund to me the total Premium Charges and Insurance Charges paid and the Account Value. Attached is the policy contract. Cited below are the reasons for the cancellation: 1.________________________________________________________ 2.________________________________________________________ 3.________________________________________________________ 4.________________________________________________________ 5.________________________________________________________ ________________________________ Signature of applicant over printed name Signature of irrevocable beneficiaries if applicable: 1.______________________________ 2.______________________________ 3.______________________________

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Notice of Cancellation

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Page 1: Notice of Cancellation

POL_ADMIN­034­0807­1 

Notice of Cancellation 

Date :     ____________________ 

To  :     COCOLIFE­Policy Service Department Cocolife Building 6674 Ayala Avenue, Makati City 

Re  :  VL Policy No. ___________________ 

I wish  to cancel my variable life  insurance coverage, please refund  to me  the  total Premium Charges and Insurance Charges paid and the Account Value. Attached is the policy contract. 

Cited below are the reasons for the cancellation: 1.________________________________________________________ 2.________________________________________________________ 3.________________________________________________________ 4.________________________________________________________ 5.________________________________________________________ 

________________________________ Signature of applicant over printed name 

Signature of irrevocable beneficiaries ­ if applicable: 

1.______________________________ 

2.______________________________ 

3.______________________________

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