OFFICIAL RECEIPT

Ground Floor, Philippine Axa Life Centre AXA Philippines is an affiliate of

Sen. Gil Puyat Avenue corner Tindalo Street Makati City P.O. Box 2390
Customer Hotline: (632) 5815-292 (AXA) | Website: www.axa.com.ph
NON-VAT REG. TIN 000-485-226-000

Received the Amount of Receipt Date

NINE THOUSAND EIGHTY TWO PESOS ONLY July 30, 2019

Policy No.: 510-3252135

Payment For:
Premium Settlement PHP 9,081.81
Overage PHP .19

Due Date: July 21, 2019 TOTAL: PHP 9,082.00

Payment in Form of :
PHP 9,082.00 By Cash

FLAMENO EFREN III C Distributor Code: 7160404018477

156 BARANGAY PAGAL Distributor Type: Agent
Cashier: PXGMAGBOO
SAN CARLOS CITY OR Number: 14520997
PANGASINAN 2420
697034972

We appreciate your business. Thank you for your confidence in AXA, the worldwide leader in financial protection.
BIR E-RECEIPTING PERMIT NO. 1011-116-00164 CBA /AR DATED 10-18-2011

CONDITIONS MENTIONED ON FACE HEREOF

1. This receipt shall not be binding on the company for any part of said payment covered by
check or any form of remittance other than cash, unless remittance is promptly honored upon
presentation of payment.

2. If this payment is not acceptable for the purpose it is offered, it will be returned accordingly
following the normal course of business.

3. This payment shall be treated as premium only if the policy to which this payment is intended
to is approved and if it is sufficient to satisfy the required premium payment. Else, this shall
be treated as a deposit until such time that all conditions mentioned are met.

4. This payment, if sufficient, shall be applied to the premium due on the policy provided that
such policy is in force on the date of payment. In case this payment is insufficient, or the said
policy has lapsed before this payment, the amount receipted shall be treated as deposit until
the amount due is paid in full within the grace period and/or until the said policy, if lapsed,
is reinstated.

5. No person, except an executive officer, with at least a Vice-President level, of the Company is
authorized to make, alter or discharge contracts or waive forfeitures.