Form Ps 29 - Application For Change Of Life & Personal Accident Policies
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1APPLICATION FOR CHANGE OF LIFE AND PERSONAL ACCIDENT POLICIES
: __________________________________________________________________
POLICY NUMBER
INSURED’ S NAME
: ________________________________________
________________
I.C. NUMBER
POLICY OWNER’ S NAME:
_________________________________________
I.C. NUMBER __________________
E-MAIL ADDRESS: __________________________________ TELEPHONE ________________ MOBILE NO_____________
Please proceed with below request changes based on the provisions of my policy, which will be effected only when
they are endorsed by the Company.
1.
INCREASE OF FACE AMOUNT
TO : _________________________________________________________
2.
REDUCE OF FACE AMOUNT
TO : _________________________________________________________
3.
CHANGE OF INSURANCE PLAN
TO : _________________________________________________________
4.
CHANGE OF MODE OF PAYMENT
TO : _________________________________________________________
5.
ADDITION OF SUPPLEMENTARY POLICIES _________________________________________________________
6.
REMOVAL OF SUPPLEMENTARY POLICIES _________________________________________________________
7.
DUPLICATE OF POLICY
REASON : _________________________________________________________
8.
CHANGE OF NAME OF
INSURED
TO : _________________________________________________________
POLICY OWNER
TO : _________________________________________________________
9.
CHANGE OF POLICYOWNER
NEW POLICYOWNER
________________________________________ I.C. NUMBER _______________
RELATIONSHIP TO INSURED
______________________________________________________________________
ADDRESS
______________________________________________________________________
10.
CHANGE OF OCCUPATION
TO : _________________________________________________________
EXACT DUTIES
______________________________________________________________________
BUSINESS ADDRESS
______________________________________________________________________
NEW ANNUAL SALARY
______________________________________________________________________
11.
OTTHER CHANGES
_______________________________________________________________________
AMOUNT OF DEPOSIT PAID WITH THIS APPLICATION
FOR INTERNAL USE ONLY
DECLARATION OF INSURED / POLICYOWNER
If the insurance program selected is with the “Right to Interest Benefit” I hereby authorize the Company to act on my behalf and
as representative and to invest upon its judgment the mathematic reserves and interest benefit, which will remain in the Company
for compound interest yielding. I also approve any relevant action on the part of the Company and accept the respective
investment return. I declare that I reserve the right to recall and cancel this authorization with a written statement addressed to the
Company.
_________________________
_______________________________
__________________________________
INSURED’S SIGNATURE
POLICY OWNER’S SIGNATURE
IRREVOCABLE BENEFICIARY SIGN.
_________________________
____________________
___________________________
_______________
ASSIGNEE’ S SIGNATURE
INS. ADVISOR SIGN.
AGENCY MANAGER’S SIGN.
DATE
PS 29
9/2014
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