REQUEST FOR POLICY CHANGE FORM

INSUREDS NAME (Please print)

_________________________________________
MAILING ADDRESS
TELEPHONE NUMBER
_________________________________________
MOBILE NUMBER
_________________________________________
REQUEST
Change name/date of birth
Insured Owner
(Attach birth certificate, marriage
contract or other legal documents)

Change Mode of Payment

Change beneficiary designation

Inclusion
Deletion
Note:
1. If more than one beneficiary is
named in any class, equal shares
shall be assumed unless
otherwise specified.
2. If beneficiary designation is
irrevocable, the written consent of
the beneficiary is required.
3.
If irrevocable beneficiary is a
minor, legal guardianship is
required.

Policy No. _____________________

Document Enclosed Health Statement
Policy Contract
Others _________

BSE Name __________________

BSE Code ___________________
Payment: P_________$_________
CR# ________ Date _________

PARTICULARS
New Name ____________________________ Former Name ___________________________
Reason Marriage to __________________________________ on ____________________
Correction
Legal Separation
Others ______________
Date of Birth _________________________
Sex Male
Female
Annual
Semi-annual
Quarterly
Monthly
Auto- Debit (Enclose Enrolment Form) Effective ____________________
Auto- Credit (Enclose Enrolment Form) Effective ____________________
Beneficiary
Name
Age
Relationship to Insured
Primary
Revocable
Irrevocable
Contingent
Revocable
Irrevocable
Trustee of Minors ________________________________________________________________
(Attach duly accomplished Trust Deed Agreement Form)
Any payment made to the above named trustee of any amount payable to the beneficiary while such
beneficiary is still below age 18 shall discharge the Company from any further liability under the policy.

Non-Forfeiture Option

Reduced Paid-up Insurance

Effective _______________________

Extended Term Insurance

Change Dividend Option

Pay in Cash
Reduce Premium

Accumulate with Interest

Purchase Paid -up Additions

Change Plan/Riders/Face
Amount

Plan _______________________________
Face Amount _________________________
Addition of Riders ___________________
Deletion of Riders ______________________
___________________________________
___________________________________
___________________________________
___________________________________

(Attach Policy Contract and Health

Statement except for reduction of
amount and deletion of riders)

Change Effective Date

Reinstatement by Redating

Redate to __________________________

(Allowed only once)

Remove/Reduce Rating
(Attach Policy Contract and Health
Statement)

Term Conversion

Medical Rating
Occupational Rating

New Occupation ____________________

since (date) __________

Attained Age
Amount Converted _____________________
Original Issue Age
New Plan _____________________________
Converting BSE _______________________________________________________________

Others (Please specify)

I/We hereby agree that should request be approved by the Company, such request shall, from the date of such approval,
amend in accordance with the terms thereof so approved the contract contained in the policy to which the request refers.
Signed on ___________________________________, ____ at _________________________________________________.
_________________________________________
Name and Signature of Witness/BSE
BSE CODE

____________________________________________________
Name and Signature of Insured
______________________________________________
Name and Signature of Owner/Assignee/Irrevocable

Beneficiary
FOR OFFICE USE ONLY
APPROVED BY ______________________________________

REMARKS
______________________
Date

OFFICE _____________________________________________
HOME OFFICE ENDORSEMENT

QR-BPLC-RPC
Rev 0
October 2009

BPI-PHILAM Customer Confidential

Page 1 of 1

Note: PLEASE ATTACH THIS FORM TO YOUR POLICY TO FORM PART THEREOF

QR-BPLC-RPC
Rev 0
October 2009

BPI-PHILAM Customer Confidential

Page 2 of 1