Pacific Cross Center

8000 Makati Avenue, Makati City, Philippines

Telephone No. (632) 899-8001
Tax Identification No: 000-440-080-000

OCC CANCELLATION REQUEST AND REFUND FORM FOR CLIENTS

Name of Policy Holder: _____________________________________________________________________

Last First Middle

Cancellation with Refund due to Visa Denial

(must be submitted within 31 days from the date indicated on the denial letter)

OCC Number: ____________________ Official Receipt Number: _________________________

Name of check payee (if other than the Principal Insured): _______________________________

Cancellation with Replacement

Reason for Cancellation: ______________________________________________

Old OCC Number: ________________ Travel Dates: ____________________

Official Receipt Number: ___________________

New OCC Number: _______________ Travel Dates: ____________________

I understand that my cancellation request is subject to the evaluation and approval of Pacific Cross. I understand that if I am applying for
refund, it will be subject to applicable cancellation fees.

Request submitted by:

____________________________________
Signature over Printed Name of Policy Holder
Date: __________________

Others
OCC Number: ____________________ Official Receipt Number: ________________

Reason: _____________________________________________________________
____________________________________________________________________

Approved by:

_________________________
Anna Maria Emmanuel Martinez
o AVP/Director for Travel Sales

SUPPORTING DOCUMENTS CHECKLIST

Required Supporting Documents for Refunds
1. Photocopy of valid I.D. of Principal Insured with visible signature
2. Photocopy of Denial Letter from the Embassy
3. Original Receipt for paid policy
4. Photocopy of passport pages if policy has commenced and refund is being requested
Note: YOU MAY BE REQUESTED TO BRING AND PRESENT THE ORIGINAL DOCUMENTS FOR VERIFICATION PURPOSES
BY PACIFIC CROSS.
Additional requirements if an authorized representative is sent to claim the refund check
1. Original and signed authorization letter from the Principal Insured
2. Photocopy of valid ID of authorized representative with visible signature
Additional requirements if check payee is other than the Principal Insured
1. Photocopy of check payee’s valid ID with visible signature
Note: AGENTS/BROKERS/TRAVEL AGENCIES ARE ALLOWED ALTERNATE CHECK PAYEES. A REQUEST
LETTER FROM THE PRINCIPAL INSURED IS REQUIRED IF NEITHER OF THE INTERMEDIARIES MENTIONED
IS THE NOMINATED PAYEE.
Required Supporting Documents for Cancellation with Replacement/Others
1. Photocopy of valid I.D. of Principal Insured with visible signature
2. Original Receipt for paid policy

This form must be submitted prior to the start date of the policy. All cancellation requests may be subject to random direct confirmation by the
Pacific Cross Internal Audit Team.