AMENDMENT FOR OFFICIAL USE ONLY GENERAL INFORMATION DETAILS OF LIFE INSURED / /

Transcription

1 PRU LIFE INSURANCE CORPORATION OF U.K. 22/F Marajo Tower, th Street West corner Fourth Avenue Bonifacio Global City 1634 Taguig City, Metro Manila, Philippines Tel s. (+632) 887 LIFE; (+632) Fax no. (+632) Write legibly and fill out all information requirements completely. If boxes provided are not enough, disregard and write in print on the space. If not applicable, write 'NA.' FOR OFFICIAL USE ONLY BRANCH TIME AM/PM RECEIVED BY/DEPARTMENT GENERAL INFORMATION DETAILS OF LIFE INSURED POLICY NUMBER SURNAME AGE (LAST BIRTHDAY) / / DATE OF BIRTH (MM/DD/YYYY) GIVEN NAME CITY OR PROVINCE OF BIRTH MIDDLE NAME OF BIRTH (MANDARY) NATIONALITY Kindly shade the appropriate circle. Male Female Mr. Mrs. Miss Others, specify Single Married Divorced Widowed Separated GENDER SALUTATION TITLE CIVIL STATUS Please indicate all other occupations if you are engaged in more than one occupation. OCCUPATION Give exact designation (If member of AFP/PNP, state rank) GROSS ANNUAL INCOME Salary Business Others SOURCES OF FUNDS NATURE OF WORK/BUSINESS (Provide brief description) ALIEN CERTIFICATE OF REGISTRATION TA IDENTIFICATION NUMBER SSS/GSIS NUMBER OTHER IDs - DETAILS EMPLOYER NATURE OF SELF-EMPLOYMENT/BUSINESS Do you currently file a tax return in the United States? page 1 AMENDMENT

2 Please provide complete address. PRESENT ADDRESS DETAILS OF TELEPHONE SUBDIVISION/BARANGAY/MUNICIPALITY/WN/DISTRICT OF MOBILE PHONE PERMANENT ADDRESS DETAILS OF TELEPHONE SUBDIVISION/BARANGAY/MUNICIPALITY/WN/DISTRICT OF MOBILE PHONE Please complete this section only if you, as the Policyowner, are not the same as the Life Insured. UPDATE EISTING CONTACT INFORMATION? DETAILS OF POLICYOWNER SURNAME GIVEN NAME AGE (LAST BIRTHDAY) CITY OR PROVINCE OF BIRTH / / DATE OF BIRTH (MM/DD/YYYY) MIDDLE NAME OF BIRTH (MANDARY) NATIONALITY Male GENDER Female Mr. Mrs. Miss Others, specify Single Married Divorced Widowed Separated SALUTATION TITLE CIVIL STATUS Please indicate all other occupations if you are engaged in more than one occupation. OCCUPATION Give exact designation (If member of AFP/PNP, state rank) GROSS ANNUAL INCOME Salary Business Others SOURCES OF FUNDS NATURE OF WORK/BUSINESS (Provide brief description) ALIEN CERTIFICATE OF REGISTRATION TA IDENTIFICATION NUMBER SSS/GSIS NUMBER OTHER IDs - DETAILS EMPLOYER page 2 NATURE OF SELF-EMPLOYMENT/BUSINESS

3 Do you currently file a tax return in the United States? Please provide complete address. PRESENT ADDRESS DETAILS OF TELEPHONE SUBDIVISION/BARANGAY/MUNICIPALITY/WN/DISTRICT OF MOBILE PHONE PERMANENT ADDRESS DETAILS OF TELEPHONE SUBDIVISION/BARANGAY/MUNICIPALITY/WN/DISTRICT OF MOBILE PHONE UPDATE EISTING CONTACT INFORMATION? DETAILS OF POLICYOWNER FOR CORPORATE CLIENTS COMPANY/BUSINESS NAME NATURE OF BUSINESS 1 Financial Institution 2 Professionally Managed Trust Others COMPANY (OR EQUIVALENT) REGISTRATION NO. OF INCORPORATION TA IDENTIFICATION NUMBER REGISTERED ADDRESS COMPANY NAME FLOOR NUMBER/BUILDING NO./BUILDING NAME OF TELEPHONE STREET/ROAD/AVENUE OF MOBILE PHONE 1 Financial institution refers to any organization that holds a banking, securities and/or life insurance license. Examples of financial institutions include banks, life insurers, custodians, asset managers and investment funds 2 Professionally managed trust is a trust that is professionally managed by a bank, custodial institution, insurance company, or investment entity that is a professional investment advisor. page 3

4 DIRECRS/PARTNERS (Please attach the updated General Information Sheet for the complete list of Board of Directors/Partners) PRINCIPAL SCKHOLDERS OWNING AT LEAST 2% OF THE CAPITAL SCK (Please attach the updated General Information Sheet for the complete list of Principal Stockholders) A beneficial owner is: (a) a person who enjoys the benefits of ownership even though title is in another person s name; or (b) any individual or group of individuals who, either directly or indirectly, has the power to vote or influence the transaction decisions regarding a specific security. BENEFICIAL OWNERS (Please attach Affidavit of Beneficial Ownership or Affidavit of Beneficial Ownership, should there be any) OTHER BUSINESS ADDRESS COMPANY NAME FLOOR NUMBER/BUILDING NAME OF TELEPHONE STREET/ROAD/AVENUE MUNICIPALITY/ CITY/ PROVINCE OF MOBILE PHONE UPDATE EISTING CONTACT INFORMATION? Is the company listed or traded on any regulated stock exchange? (If no, please complete the question below. If yes, please ignore the question below) 3 Does any US person/entity, directly or indirectly, own more than 10% of the organisation? 3 Defined as one of the following: - Citizen or resident of the US - A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States - Any US estate - Any US trust subject to US supervision and substantially controlled by a US person SUBSTITUTE DECLARATION STATEMENT Mark with if the declaration statement below is applicable. Please complete the declaration statement below. Mark with if the declaration statement below is not applicable. Ignore the declaration statement below. Declaration Statement I, (authorised signatory), (title) for and in behalf of (name of company (or equivalent)), declare that the above company (or equivalent) is not any one of the following: (a) financial institution; (b) professionally managed trust; (c) non-listed entity of which more than 10% is owned by any US person/entity; or (d) required to file a tax return in the United States. FORM COMPLETED/INFORMATION SUPPLIED BY: NAME OF AUTHORIZED REPRESENTATIVE POSITION Signature of authorized representative / / DATE (MM/DD/YYYY) page 4

5 DETAILS OF POLICY AMENDMENT REQUEST NAME LIFE INSURED POLICYOWNER BENEFICIARY/IES (For new beneficiaries, additional information are required on page 7) FOR NEW INDIVIDUAL POLICYOWNER, PLEASE COMPLETE THE FOLLOWING DETAILS: Do you currently file a tax return in the United States? CITY OR PROVINCE OF BIRTH OF BIRTH (MANDARY) NATIONALITY PRESENT ADDRESS DETAILS OF TELEPHONE SUBDIVISION/BARANGAY/MUNICIPALITY/WN/DISTRICT OF MOBILE PHONE FOR EISTING INDIVIDUAL POLICYOWNER: ADDRESS OF INDIVIDUAL POLICYOWNER RESIDENCE BUSINESS BIRTHDATE/AGE OF ADDRESS BIRTHPLACE OCCUPATION OF ADDRESS page 5

6 FOR NEW ENTITY POLICYOWNER, PLEASE COMPLETE THE DETAILS OF POLICYOWNER FOR CORPORATE CLIENTS ON PAGE 3. FOR EISTING ENTITY POLICYOWNER: ADDRESS OF CORPORATE CLIENT REGISTERED ADDRESS OTHER BUSINESS ADDRESS OF ADDRESS CHANGE OF NATURE OF BUSINESS Financial institution Financial institution Professionally managed trust Professionally managed trust Others Others CHANGE OF AUTHORIZED SIGNARY CHANGE OF SUBSTANTIAL UNITED STATES (US) BENEFICIAL OWNERS PLAN CHANGE CONVERT SUM ASSURED/BENEFIT AMOUNT/PREMIUM INCREASE Effectivity date of inclusion/deletion of rider is on the next due date of the policy. Rider premium term follows the premium term of the basic plan. REDUCE RIDERS INCLUDE DELETE MODE OF PAYMENT ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY PHP/USD PHP/USD METHOD OF PAYMENT Cash Automatic debit arrangement Post dated cheques Credit card BANK ACCOUNT DETAILS ACCOUNT HOLDER: ACCOUNT TYPE AND NO.: NAME OF BANK: DEPOSIRY BRANCH: *For monthly mode of payment, strictly require submission of the following: - 12 Post Dated Checks (PDCs) with PDC Certification and PDC Monthly Agreement Form; or - 3 Original Copies of Auto-Debit Arrangement (ADA) Enrollment Form; or - Credit Card Enrollment Form and photocopy of credit card (front portion) EFFECTIVE DATE GUARDIAN/TRUSTEE ADD CHANGE DELETE NON-FORFEITURE OPTION CASH VALUE REDUCED PAID-UP AUMATIC PREMIUM LOAN ETENDED TERM INSURANCE CASH VALUE REDUCED PAID-UP AUMATIC PREMIUM LOAN ETENDED TERM INSURANCE page 6

7 DIVIDEND OPTION DIVIDEND SUB-OPTION CONSENT PAID IN CASH USED PAY FOR PREMIUM USED BUY PAID-UP INSURANCE LEFT ACCUMULATE AND EARN INTEREST ORDINARY ACCUMULATION SELF-LIQUIDATION FULLY PAID-UP EARLY MATURITY CASH ALLOWANCE PAID IN CASH USED PAY FOR PREMIUM USED BUY PAID-UP INSURANCE LEFT ACCUMULATE AND EARN INTEREST ORDINARY ACCUMULATION SELF-LIQUIDATION FULLY PAID-UP EARLY MATURITY CASH ALLOWANCE I AGREE USE ANY DIVIDEND ACCUMULATION OF THE POLICY WARDS ANY PREMIUM DEFAULT OPTION IN EFFECT * I for Irrevocable and R for Revocable. Unless otherwise specified, beneficiaries are assumed revocable. Provisions on beneficiary or beneficiary designation follow those stated in beneficiary designation form. Beneficiary details From To Date of birth Relationship I/R* Primary beneficiary Add Replace all Secondary beneficiary Add Replace all For the new beneficiaries, add: Delete Correction Delete Correction Present address Employer Permanent address Contact no. Others This form should be completed and signed for any increase in insurance coverage, inclusion of riders or any request involving additional risks. DECLARATIONS Applicable due to additional risk t applicable Since the date of the original application, Life Insured Policyowner a. has continued in good health; b. has not made an application for insurance which has been declined; c. has no other application for insurance pending with any other company at the present time; d. has not consulted or been examined by a physician or a practitioner; and e. his insurability as a life insurance risk has not been changed by any event or circumstance. If there are any exceptions to any of the statements in the Declaration of Insurability, give full details on the space provided. Please provide details if you answered no to any of the following questions. PRU LIFE INSURANCE CORPORATION OF U.K. Head Office: 22/F Marajo Tower, th Street West corner Fourth Avenue, Bonifacio Global City, 1634 Taguig City, Metro Manila, Philippines Tel s. (632) 887 LIFE, (632) , PRULINK Fax: (632) contact.us@prulifeuk.com.ph Website: This form should be completed and signed for any increase in insurance coverage, inclusion of riders or any request involving additional risks. Signature over printed name of LIFE INSURED Signature over printed name of IRREVOCABLE BENEFICIARY/IES Authorization to Furnish Medical Information The Life Insured and any Payor/Policyowner authorizes PRU LIFE INSURANCE CORPORATION OF U.K. to obtain medical information from hospitals, medical facilities and physicians. PRU LIFE INSURANCE CORPORATION OF U.K. is also authorized to convey relevant information contained in the application documents resulting from the contract implementation to the reinsurer and to other insurers, as well as to receive from them or from third parties information from assuming the risk. A photocopy of this authorization shall be valid as the original. page 7 Signature over printed name of POLICYOWNER (If other than the LIFE INSURED) Signature over printed name of AGENT as WITNESS

8 DECLARATIONS Please read carefully before signing this application and refer to your policy booklet for more information. I have read the foregoing Policy Amendment Request form and understand the terms and conditions stated therein, and thereby give my consent to the foregoing amendments. I/We declare that the above statements I/we made are true and complete and that all exceptions have been stated. The Life Insured or the Policyowner (if other than the Life Insured) further agrees that the above changes shall be an amendment to and shall form part of the original application and of the policy issued thereunder, if any, and that they shall be binding on any person who shall have or claim any interest under such policy. You agree that we may disclose your particulars or any information to any Authority (governmental and other regulatory authority or self-regulatory body in various jurisdictions) in connection or adherence (whether voluntary or otherwise) with the Applicable Requirements (laws, regulations, orders, guidelines, codes, market standard, good practices and requests of or agreements with any Authority as promulgated and amended from time to time). Such disclosure may be effected directly or sent through any of our Head Office(s) or other related corporations or in such manner as we deem fit. For the purposes of the foregoing and notwithstanding any other provision in this Agreement or any other agreements between us, we may need you to provide us with further information as may be required for disclosure to any Authority and you shall provide the same to us within such time as may be reasonably required. You hereby agree to consent to the use and transfer of your particulars under Republic Act.10173, the Data Privacy Act of 2012, and Presidential Decree or any applicable data protection legislation from time to time in force. You agree to update us in a timely manner of any change of any of the details previously provided to us whether at time of application or at any other times. In particular, it is very important that you notify us immediately if, where you are an individual, your nationality, tax status or tax residency changes or if you become a tax resident in more than one country, or, where you are a corporation or any other type of entity, your registered address, address of your place of business, substantial shareholders, legal and beneficial owners or controllers (who own or control more than 10% of your shares or ownership interest or control), tax status, tax residency changes or if you become a tax resident in more than one country. If any of these changes occurs or if any other information comes to light concerning such changes, we may need to request certain documents or information from you. Such information and documents include but are not limited to duly completed and/or executed (and, if necessary, notarized) tax declarations or forms. Executed at this day of 20. Signature over printed name of LIFE INSURED Signature over printed name of EISTING POLICYOWNER (If other than the LIFE INSURED) Signature over printed name of IRREVOCABLE BENEFICIARY/IES Signature over printed name of NEW POLICYOWNER (if any) Signature over printed name of AGENT as WITNESS page 8