ENROLLMENT / UNDERTAKING BPI-PHILAM LIFE ASSURANCE CORP.

COPY
For Automatic Debit Arrangement (Please send back to any BPI-PHILAM Office)

Fill-out ONLY if enrollment is to be coursed through BPI-Philam Life Assurance Corp.:

Acknowledge Bank Reference Number ______________ for Auto-Debit transactions under BPI-Philam Life Assurance Corp. Policyholder __________________________ payments.

Certified/Verified by:

______________________________ _______________________________
POS Assistant POS - Manager

Lou Ann Paguirigan 7003815801 for and in

I, ________________________________________, the Payor of BPI-Philam Life Assurance Corp. Contract with Policy No. ____________________,
consideration of my availment of the Automatic Debit Arrangement (ADA) to pay for the above-mentioned policy agree:

1. That my Insurance premium to BPI-Philam Life Assurance Corp. shall be paid through an automatic transfer of payment from my enrolled BPI Account No/s
SA _____ CA_____ Account Number _ _ _ _ _ _ _ _ _ _ Branch of Account _____
To BPI-Philam Life Assurance Corp.’s SBA Account No. < 8113-1168-98>

2. That the first debit date for my insurance premium from the above-mentioned BPI account shall be on __________. Subsequent debits shall be made regularly
according to the scheduled date/s of my chosen mode of payment, which is __________ so long as the status of my insurance policy is inforce.

3. That BPI-Philam Life Assurance Corp. in case of failed auto-debit payment for my current due premium, shall process auto-debit retry a week after the first-auto debit
attempt and on the succeeding week until a successful auto-debit is processed, provided the maximum number of three (3) unsuccessful debit attempts have not been
reached. In relation to this, BPI-Philam Life Assurance Corp. shall inform me within the grace period on the status of the auto-debit transaction, whether it was
successful or unsuccessful debit attempt.

4. That I shall notify and apply with BPI-Philam Life Assurance Corp. at least one (1) month before the debit date should I decide to cancel the ADA.

5. That I am aware that I will not receive Billing Notices and hereby waive such notices on my insurance policy while the ADA is active and enforceable and instead I will
receive Short Messaging System (SMS) Messages from the Company (once E-Text Facility of Payee-Company is in place).

6. That in case the E-Text Facility is already in place, BPI-Philam Life Assurance Corp. may send any notices at my cellphone number ____________________ related to
my availment of auto-debit facility for my policy payments. I shall also notify BPI-Philam Life Assurance Corp. in case of any changes in my cellphone number.

7. That I shall pay the corresponding premium due plus any overdue interest through over-the-counter payment facility at BPI in case of three (3) unsuccessful auto-debit
attempts or once my policy turned to lapse or converted to Extended Term Insurance (ETI) or Reduced Paid Paid-up Insurance under the Non-Forfeiture Option
provision of the policy due to several unsuccessful debit attempt. If the policy remains inforce, the next attempt to debit shall automatically resume on the debit date
corresponding to the next premium due.

8. That the debit attempts shall be temporarily discontinued is the unsuccessful debit resulted to the policy’s lapsation or conversion to Extended Term Insurance (ETI) or
Reduced Paid-up Insurance (RPU) under the Non-Forfeiture Option provision of the policy. The next debit attempt shall automatically resume on the debit date
immediately following the policy’s reversion to inforce status and provided that the enrolled account is still active.

9. That I am aware that my ADA will be cancelled automatically for any of the following reasons:

a) Account has been closed;

b) Policy has been full paid (except when there is approved ADA for loan payments);
c) The insurance coverage has been terminated due to expiry, surrender or maturity:
d) Upon knowledge of death of the insured:
e) The ADA has remained inactive (no debit attempt has been made) for the last twent-four (24) months.

10. That I shall re-enroll another account in case my previous enrolled account has been closed or ADA is terminated due to inactive ADA on my account. Failure on my part
to re-enroll another account shall not entail liability on the part of the Company in case my policy turned to lapse.

11. That I shall inform BPI-Philam Life Assurance Corp. immediately in case my enrolled account is lost in order for the needed cancellation to the system, re-enrollment of
new account or amendment to a different payment option. Failure on my part in notifying BPI-Philam Life Assurance Corp. (BPLAC) shall not entail liability on the part of
the Company in case my policy turned to lapse or unsuccessful continuous charging for payment was made on the account.

May
28th day of _______________,
Signed this __________ 2018 at ______________________________________.
__________ Manila
Payor: Certified/Verified by:

___________________________ ___________________________
(Signature over Printed Name) (Signature over Printed Name)

BPLAC HEAD OFFICE USE ONLY:

Processed By: ______________________________ Approve Disapprove: due to ____________________
(Signature over Printed Name)

QR – BPLC – ADA BPLAC Customer Confidential

Revision 0
November 2009