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Life Certificate

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Payee Name*

Do Not Edit.
Payee for Policy Entered : Please Enter Policy Number below.
Policy No.*

One Policy per Transaction. Do NOT include any space or any other words other than policy numbers . Please include the POLICY PREFIX : ERA / URA / RAP ALSO WAIT FOR ANNUITANT NAME TO SHOW
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Other Policies

Please add other policy numbers here. Use a ; as a separator. Do NOT include any space or any other words other than policy numbers .
Is the Payee's Name matched with the person currently submitting this life certificate?*
- Yes
- No
Salutation
First Name*
Middle Name
Last Name*
Contact No.
Email
Address
Address 1
Address 2
Town/City*
Country*
Banking Information
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Institution Name
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Address
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Account Number
Is the information above the same as previously stated?
- Yes
- No
Please select the information that you would like to update
Hold CMND on Mac or CNTR on Window to select multiple options.
Salutation
First Name*
Middle Name
Last Name*
Address 1
Address 2
Town/City*
Country*
Contact No.
Email
Name*
Address*
Account Number*
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Please select witness
Witness
Is the Witness a Resident or Non Resident?
- Resident
- Non Resident
Please select the witness
Please select the witness
First Name*
Middle Name
Last Name*
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Signature of Witness
- Type-in Signature
- Digital Signature
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Signature
Signature*
Date and Stamp
MM slash DD slash YYYY
Stamp here:
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Signature of Policyholder
- Digital Signature
- Type-in Signature
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Signature
Comments
Any Comments, Add here.
Branch of Request*
Signature*
Date*
MM slash DD slash YYYY
Would you like a copy of your Life Certificate to be sent via email?*
- Yes
- No
Please answer yes only if you have an email address.
Email*

Email will be automatically Sent to Email Address above
Selfie Attachment
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
Please take a selfie to verify Person filling out form.
Last Updated: November 7, 2024

Life Certificate

Payee for Policy Entered : Please Enter Policy Number below.

Address

Banking Information

Witness

Stamp here: