INDEMNITY AGREEMENT

Surrender



WHEREAS, THE PHILIPPINE AMERICAN LIFE AND GENERAL INSURANCE COMPANY did issue its Policy
No. ___________________ on the ___________ day of ________________, 200___, on the life of
___________________________________________________ in the sum of (________________) Dollars/Pesos, and


WHEREAS, the said Policy has been lost, destroyed, or mislaid, and


WHEREAS, the said THE PHILIPPINE AMERICAN LIFE AND GENERAL INSURANCE COMPANY, at the
request of the undersigned, has consented to pay the sum due on said policy to ________________________________
without satisfactory evidence relative to the beneficiary designation in the Policy, and without surrender of said Definitive
Policy, provided the undersigned will covenant to indemnify and save harmless said Company in so doing:


NOW, THEREFORE, We, the undersigned ____________________________, as Principal, and
______________________________ and ____________________________ as Sureties _______________________
citizens , of legal age, and residing at ___________________________, Philippines, in consideration of the payment to
the said Principal of the sum due on said Policy No. ______________, do hereby jointly and severally bind ourselves, our
heirs, representatives and assigns, to indemnify and save harmless THE PHILIPPINE AMERICAN LIFE AND GENERAL
INSURANCE COMPANY from any and all actions, causes of action, claims and demands growing out of any interest in or
to said Policy or any assignment thereof which anyone may have or claim to have against the Company.


IN WITNESS WHEREOF, we have hereunto set our hands this __________ day of _________________,
200___, at _____________________, Philippines.


________________________________
PRINCIPAL


________________________________
SURETY


________________________________
SURETY

IN THE PRESENCE OF:
__________________________________
__________________________________

REPUBLIC OF THE PHILIPPINES)
) S.S.
_____________________________)

Before me, the undersigned Notary Public in and for ____________________________ personally appeared
___________________, with Residence Certificate No. ________________ issued at ____________________ on
________________, 20___, _______________________, with Residence Certificate No. ________________ issued at
____________________ on ________________, 20___, _______________________, with Residence Certificate No.
________________ issued at ____________________ on ________________, 20___ respectively, known to me and to
me known to be the same persons who executed the foregoing indemnity agreement, and acknowledged 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 notarial seal at ___________________,
Philippines, this ________ day of _______________, 20___.

NOTARY PUBLIC

My commission expires on ______________
Doc. No. ________
Page No. ________
Book No. ________
Series of 20______
QR-PBAO-IAF
Revision 3
May 2010 PHILAM LIFE CUSTOMER CONFIDENTIAL