POLICY ASSIGNMENT FORM
AGENT CODE POLICY NUMBER:
NOTE: Fill out with block letters. Put on the
tick boxes representing options.
PART I - CONTACT INFORMATION UPDATE
I agree to update my contact information record with AIA Philippines based on the details in this section.
LAST NAME TELEPHONE Residence Office
FIRST NAME MOBILE PHONE (ex: +63-900-1234567)
MIDDLE NAME EMAIL ADDRESS
If you want to receive e-notices in lieu of hard copy billings, accomplish the
E-Notice Enrollment Form
PREFERRED MAILING ADDRESS Residence Office
(House/Building/Lot No., Name of Street, District, City, Province, Zip Code)
DATE OF BIRTH (MM/DD/YYYY) PLACE OF BIRTH NATIONALITY
SOURCE OF FUNDS
SEX Male Female GENDER Male Female
(defined as gender at the TIME OF BIRTH) (defined as gender at the TIME OF CLAIMS APPLICATION)
OCCUPATION TYPE OF ID
NAME OF EMPLOYER/BUSINESS ID NUMBER
NATURE OF BUSINESS
PART II - REQUESTED TRANSACTION
ASSIGNMENT OF POLICY
IMPORTANT NOTICE: The Assignee may be a Natural or Juridical Person. AIA Philippines assumes
no responsibility over the legality or validity of the assignment of this policy to a third party.
Assignee
Authorized Signatory Position of Authorized Signatory
Telephone Number of Assignee (ex. 044 1234-5678) Mailing/Business Address of Assignee
Amount Assigned
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POLICY ASSIGNMENT FORM
PART II - REQUESTED TRANSACTION
For valuable consideration, I hereby assign, transfer and convey unto said assignee the death benefits of subject
policy up to the extent of amoung assigned indicated above; Provided that endowment proceeds, hospitalization
and disability benefits and other living benefits of this Policy remain payable to the insured/policyowner while alive;
Provided, that any act that may result in the reduction of the face amount or termination of the subject Policy shall
be with the express written consent of the assignee; Provided, that this assignement is being made subject to the
provisions and conditions of the said policy and shall remain effective until AIA Philippines is formally advised by
the assignee of the termination thereof.
CANCELLATION OF ASSIGNMENT OF POLICY
This is to formally advise AIA Philippines of the cancellation and termination of the assignment of the subject policy.
As such, all rights and privileges of the assignee thereunder are hereby cancelled and immediately restored to the
policyowner.
PART III - SIGNATURE
WARNING: FILING OF FRAUDULENT CLAIM IS PENALIZED BY LAW
Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed
and/or imprisonment of two (2) years, or both, at the discretion of the court, to any person who presents or
causes to be presented any fraudulent claim for the payment of a loss under a contract of insurance, and
who fraudulently prepares, makes or subscribes any writing with intent to present or use the same, or to
allow it to be presented in support of any claim.
PLEASE DO NOT SIGN ON A BLANK FORM
DATA PRIVACY NOTICE. The Company values your privacy and abides by the Principles of Transparency, Legitimate
Purpose and Proportionality enshrined in the Philippine Data Privacy Act of 2012. Accordingly, the Company
processes, using any medium, any information pertaining to this application or insurance policy and all submitted
documents, to provide our insurance and investment products and services. The information and documents are also
disclosed to the Company’s affiliations (including but not limited to any of its subsidiaries/affiliates in the Asia
Pacific Region), its Brokers, Agents, and their employees and staff and to accredited/affiliated third parties or
independent/non-affiliated third parties, whether local or foreign. The Company will upload your medical information
to a Medical Information Database accessible to life insurance companies for the purpose of enhancing risk
assessment and preventing fraud. Once uploaded, all life insurance companies will only have limited access to the
said medical information in order to protect your right to privacy in accordance with law. A copy of Circular Letter
No. 2016-54 may be accessed at the Insurance Commission’s website at [Link].
Your information and documents are retained by the Company (a) from execution until seven (7) years after
termination of your policy, for hard documents in paper form, and (b) from execution until ten (10) years after
termination of your policy, for documents in electronic form; but in no case shorter than may be required by
appropriate orders and regulations. Your information will be deleted/destroyed after this period.
The Company will use such information in the insurance policy and all related documents to conduct automated
processing, data analytics, profiling, historical research (a) to improve the Company’s internal systems and
processes, (b) for actuarial assumptions, (c) in internal and external company reports, and (d) to develop and
implement business strategies.
I/We hereby authorize any person, organization, or entity that has any record or knowledge of my health and/or
that of the insured to give AIA Philippines any and all information relative to any hospitalization, consultation,
treatment or any other medical advice or examination. This authorization is in connection with the application
for reinstatement/policy change/removal or reclassification or rating therefrom. A photographic copy of the
authorization shall be valid as the original.
DATA PRIVACY CONSENT
I/we agree for the Company to use the information in the insurance policy and all related documents in the design
and communication of the Company’s marketing campaigns and offers in order to improve the quality of service
the Company provides, and to receive such marketing campaigns. I/we agree to share the information in the
insurance policy with th ird parties for marketing campaigns.
I/we agree for the Company to use such information for profiling to develop, enhance and offer me/us financial
services and products that the Company considers as suitable for my/our insurance and other financial needs.
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POLICY ASSIGNMENT FORM
PART III - SIGNATURE
I/we may at anytime withdraw our consent by calling AIA Philippines' contact center, or by emailing the request to
dpo@[Link]. Upon receipt of such withdrawal of consent, the Company will no longer approach me/us for
promotions or products that may be suited to my/our insurance needs. I/We am/are assured that this will not affect
the Company's ability to provide quality service in relation to my/our existing policies. Please visit the Company's
website, [Link] for our Privacy Statement, which provides further details on why your personal data is
collected, how it is intended to be used, to whom your personal data may be transferred to, how to access, review and
amend your personal data, and our policies on direct marketing.
Place Signed Date Signed (MM/DD/YYYY)
SIGNATURES OVER PRINTED NAMES
Owner Irrevocable Beneficiary Assignee Agent/Witness
A Privacy Addendum concerning the Personal Information Protection Law (PIPL) of the People’s Republic of China is available at
Shared PIPL Addendum - BPI AIA and AIA PH
The Privacy Addendum above only applies if you are within Mainland China
PART IV - ACKNOWLEDGEMENT
REPUBLIC OF THE PHILIPPINES
_________________________________
_________________________________
_________________________________
Before me, the undersigned Notary Public in and for ___________________________________ personally appeared
_____________________________ with Competent Evidence of Identity: ______________________________________
______________________________________
known to me and to me known to be the same person who executed the foregoing Agreement, and
acknowledged to me that they executed the same as their own free and voluntAry act and deed.
IN WITNESS WHEREOF , I have hereunto set my hand and affixed my seal at _______________________________ ,
Philippines, this ___________ day of _____________________________ , 20 _____ .
Doc. No. _________________________________
Page No. _________________________________ ________________________________________
Book No. _________________________________ NOTARY PUBLIC
Series of 20 _________________________________ My commission expires December 31, 20 ___
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