Lost PPolic

Lost olicy Declar

olicy Declaraation

Please PRINT clearly. In this form, you and your refer to the policyowner, while we, us, our and the Company refer to
Use BLACK ink. Sun Life Grepa Financial, Inc., a member of the Sun Life Financial group of companies.

You hereby request the Company to issue a Memorandum setting out some details of the policy
according to the Company’s records for the policy at this time. You understand that the Memoran-
dum will not be a replacement for the policy. The Memorandum will be returned to the Company if
the policy is found.

1 General Information
Policy Owner (Last Name, First Name, M.I.)

Policy Number

2 Signatures
By signing below, you hereby declare that you have been unable to find the above-numbered policy
and that you have no knowledge of any other person who might be in possession of the policy.

You warrant that the Company can rely on the truthfulness of your declarations herein for this and all
future transactions relating to the policy identified. You hereby agree to indemnify and hold harmless
the Company from any loss, costs or expense to which it may be put by relying upon your statements
under oath and relying upon this document. This provision does not in any way prejudice the
Company from taking, simultaneously or successively, further action which it may be entitled to
under the law.
This section must be
Signature of Policy Owner Printed Name
signed by you and the
policy owner all of your
X
irrevocable beneficiaries, Signature of Irrevocable Beneficiary, if any Printed Name
if any, by the Assignee, if X
any, and by the appro-
priate persons as Signature of Irrevocable Beneficiary, if any Printed Name
indicated. X
Signature of Assignee , if any Printed Name
X
Signature of Witness Printed Name
X
Place of Signing Date of Signing (day/month/year)

3 Notarization

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 _____________

00LPD.2.08 *00LPD.2.08*