CIU COVER

Customer Information

Form

Always Listening. Always Understanding.

Please submit a photocopy (both sides) of any valid ID, together with this Customer Information Form.

You can also fax or e-mail the Customer Information Form through the following:

Metro Manila Regional OfficeG/F SSHG Law Center105 Paseo de Roxas Legaspi Village, 1226 Makati CityTel No.: (+63 2) 884-8484

Head Office Customer CenterG/F Marajo Tower, 312 26th Street West corner Fourth Ave.Bonifacio Global City. 1634 Taguig CityTel No.: (+63 2) 884-8484

Cebu Regional OfficeG/F TGU Towers, Asia Town IT Park Salinas Drive, Apas, Cebu City 6000Tel No.: (+63 32) 238-7888

Davao Regional Office5/F Units 52 to 55 Landco Business Center, Bajada Davao City 8000Tel No.: (+63 82) 224-4777

Pru Life UK Branches and General Agencies(To know the complete adddress of our Branches and General Agencies in your area, please contact our Pru Customer Action Team, through the hotlines below.)

What to submit

Where to submit

Metro Manila Las PiñasMandaluyongManila (Escolta)Makati (Salcedo Village)Muntinlupa (Alabang)Pasig (Ortigas)Quezon City – SM North EDSAQuezon CIty – Novaliches

LuzonAlbay (Legazpi)BaguioBataanBatangas (Lipa)BulacanCagayan (Tuguegarao)Camarines Sur (Naga)

CaviteIlocos Norte (Laoag)Isabela (Cauayan and Santiago)La UnionLaguna (Calamba and Sta. Rosa)Nueva Ecija (Cabanatuan)Pampanga (San Fernando)Pangasinan (Dagupan)Pangasinan (Mangaldan)Quezon (Lucena)Rizal (Antipolo)SorsogonTarlac

VisayasBohol (Tagbilaran)Capiz (Roxas City)

CebuIloiloLeyte (Ormoc and Tacloban)Negros Occidental (Bacolod)Negros Oriental (Dumaguete)

MindanaoAgusan del Norte (Butuan)DavaoGeneral Santos CityLanao del Norte (Iligan City)Misamis Oriental (Cagayan De Oro)

The following are considered as valid IDs:•Passport•Driver’s license•Professional Regulatory

Commission (PRC) license•National Bureau of Investigation

(NBI) clearance•Police clearance•Firearms license•Bureau of Internal Revenue (BIR)

ID with photo•Social Security System (SSS) ID

with photo

•Government Service and Insurance System (GSIS) ID with photo•PhilHealth card•Senior Citizen card•Postal ID•Voter’s ID

For minors (persons under 18 years of age):•Photo-bearing school ID signed by

the principal or head of school•Birthcertificate•Library ID

SV

ETC

IUF0

5251

1-10

0120

13

Pru Customer Action Team HotlinesFax: (+63 2) 840-1528E-mail: contact.us@prulifeuk.com.phHotline: (632) 887-LIFE (5433) within Metro ManilaDomestic Toll Free: 1-800-10-PRULINK (7785465)

Support Services – ConservationFax: (+63 2) 370-2990 local 3333Tel.: (+63 2) 884-8484 local 5563 and 5575

CIU INSIDE

Dear PRUPolicyholder,

Pru Life UK is a Company that listens to and understands your needs. We have committed ourselves to providing you with innovativeproductsandservicesthatfulfillyourchangingfinancialsecurity and risk protection needs.

As one of our valued PolicyHolders, we want to ensure that the information that we have on record about you and your Policy/ies are always updated so that we can properly address your queriesandattendtoyourpolicy-servicingneeds.Kindlyfilloutthis Cusomer Information Form and submit this to us together with a copy of your valid ID. Rest assured that all customer information willbekeptconfidential.

Thank you for entrusting your future to Pru Life UK.

George M. OpedaExecutiveVicePresidentandChiefOperationsOfficer

Survey instructions

Personal information

Contact information

Policy number

Policy Owner declaration and authorization

In compliance with the Anti-Money Laundering Act (AMLA)

PleaseprovidecompleteinformationbyansweringallthefieldsintheCustomer Information Form and indicateN/A infields thatarenotapplicable.

Last name First name Middle name c Male c Female

Date of birth (mm/dd/yy) Place of birth

Citizenship Country of origin

Doyoucarryanyothercitizenship/passport/workpermitorpermanentresidencecertificatefrom any other country other than what you stated above? If yes, please state which country.c Yes __________________________________ c No

SSS/GSIS no./Other ID (Indicate ID type) TIN no.

Marital statusc Unmarried/Single c Divorced/Annulled c Widowed c Married c Separated

Spouse’s name

Spouse’s date of birth

Mother’s full maiden name

Child/children’s name/s (Last name/First name/MI) Birth date (mm/dd/yy)

1.

2.

3.

4.

Home address

_______________________________ _____________________________________Room / house / building Street / barangay / municipality

________________________________________________ ____________________Town / city / province Zip code

Home phone (landline) Personal mobile phone

E-mail address

Employer or business name (if self-employed)

Position in the company

Employer / business address (if self-employed)

_______________________________ _____________________________________Room / house / building Street / barangay / municipality

________________________________________________ ____________________Town / city / province Zip code

Business phone (landline) Business mobile phone

E-mail address

Where do you wish to receive your billing statement and other correspondences from Pru Life UK?c Home address c Business address

Kindly indicate the policy numbers of your Pru Life UK policies

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

I certify that the above information are true and correct. I further authorize Pru Life UK to (Please check.):

c Amendmyexistingcustomerinformation/recordtoreflecttheaboveinformationin relation to my Policy/iesc Sharespecificinformationwithpartnersandaffiliatesandallowmetoavailofspecialoffersandbenefitsresultingfromcross-marketingandco-brandinginitiatives

Signature over printed nameX

Date completed

CIU INSIDE