REQUEST FORM
(POLICY BENEFIT)
Version – 01/31/2024
POLICY INFORMATION:
NAME OF INSURED/OWNER: ______________________________________ Date : ____________________
LA UNION
POLICY NUMBER : ______________________________________ Branch/Signed at : ____________________
Control No SFL-2024-
: ________________________
CONTACT NUMBER : ___ ___________________________________
E-MAIL ADDRESS : _______________________________________
PRESENT ADDRESS : ____________________________________________
REQUEST DETAILS:
Policy loan
Refund Replacement of Check
Unclaimed Benefit Fund (UBF) / Endowment Type of Transaction Check No. Check Date Amount Reason
Premium Deposit Fund Withdrawal
Partial
Full
PAYMENT INSTRUCTION:
Waiting For pick up:
For deposit to personal bank account Note: Submit an authorization letter and ID if authorized representative
AUTHORIZATION to DEPOSIT
This is to authorize Fortune Life Insurance Company, Inc. to deposit my Policy Benefit to my personal bank account, details below:
Account Name : ______________________ Account Number: ___________________
Type of Account : _______________________ Name of Bank : ___________________
Address of Bank : _______________________
It is fully understood that any discrepancy on the above details, Fortune Life Insurance Company, Inc., will not be held accountable. Likewise,
bank charges and other fees due to discrepancy, shall be automatically deducted from the proceeds of my Policy Benefit.
CONFORMITY
I certify that the above mentioned pieces of information are true and correct and that I hold free and harmless and indemnity Fortune Life
Insurance Company, its stockholders, officers, employees and agents from any claims arising from the use of information and the deposit of
the benefit to the account number.
DATA PRIVACY CONSENT
In compliance with the Data Privacy Act (DPA of 2012), and its Implementing Rules and Regulations (IRR), I allow Fortune Life Insurance
Company and its agents, third parties, government agencies and instrumentalities to collect, use, share and retain my personal data relative to
my insurance policy. This consent will continue to be in effect throughout the duration of my policy and/or until the expiration of the retention
limit prescribed by the law and subject to the company’ s data privacy policy https://web.fortunelife.com/about-us/data-privacy
Insured/Owner
Signature Over Printed Name
Conformed by:
Witnessed by: Authorized Representative:
______________________________
Signature Over Printed Name
Irrevocable Beneficiary/ies
Signature Over Printed Name Signature Over Printed Name
Signature Over Printed Name
Insured / Owner Witnessed by:
Signature Over Printed Name
