*PPH1PCRFM1*
Policy Number(s)
Policy Change Request Form
Important Notes:
1. This form is to be accomplished by the Policy Owner/Assignee in BLOCK LETTERS.
2. Please do not sign on a blank form.
3. Please put a shade in the circle to indicate your choice(s).
FOR OFFICE USE ONLY
Request types (Maximum 5 service requests)
Date Received: ____________
Time Received: ____________
Non Financial Changes Financial Changes Receiving
Contact Information Payment Mode Dept./Office: ______________
Beneficiary Information Payment Method
Transfer of Ownership Index-Linked Increase Endorsement (IIE)
FOR DISTRIBUTOR’S USE ONLY
Autopay Cycle Policy Coverage Increase/Decrease FE/Advisor’s code:
Dividend Options Term Conversion
__________________________
Death Benefit Option
FE/Advisor’s name:
Non Forfeiture Options
__________________________
Personal Particulars
FE/Advisor’s mobile number:
__________________________
Policy Details
Full Name of Insured (Last Name, First Name, Middle Initial)
Phone No. Cellphone No. Email
Full Name of Policy Owner (Last Name, First Name, Middle Initial)
Phone No. Cellphone No. Email
Full Name of Assignee
Phone No. Cellphone No. Email
Contact Information Changes
Notes:
New Mailing Address
Pls. provide proof of identification
House/StreetNo./Brgy City ZipCode for changes in personal
information.
Address outside the Philippines
is NOT allowed.
Residence Telephone Number Mobile Number
Office Telephone Number Email Address
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Policy Change Request Form
Beneficiary Changes
Please include all beneficiaries’
Relationship Share Date A/D names as this change will
Complete Name P/C R/I supersede the previous
to Insured (in %) of Birth /C
designation.
Please write the designation/
choices on the appropriate field.
Legend:
R : Revocable
I : Irrevocable
P : Primary
C : Contingent
A : Add
Transfer of Ownership (Absolute Assignment) D : Delete
C : Change
From: Name of Previous Owner
If reason for change in Owner is
To: Name of New Owner due to the death of the previous
Owner, pls. attach a copy of the
death certificate.
Sex Date of Birth (yyyy/mm/dd) Relationship of New Owner to
Insured: Designation of a minor as
Male Female Owner is discouraged.
Reason for change in Owner
Signature of New Owner * If change of correspondence address is needed, please complete
Correspondence Address Change part
** If the New Policy Owner will act as the Payor of the poicy, please
complete Health Statement Form
Change in Payment Mode
Annual Semi-Annual Quarterly Monthly
For monthly mode of payment,
Change of Payment Method auto-collection payment method
is required.
Auto Debit Arrangement (ADA) Credit Card Post-Dated Check Cash Others __________ To apply for automatic payment
facility, please complete the
Direct Debit Authorization (DDA)
form or Credit Card Payment
Change in Autopay Cycle (Applicable for Auto Debit Arrangement only) Authorization (CCPA) form.
First Cycle Second Cylce
Dividend Option/Non-Forfeiture Option (NFO) Changes
Applicable to non investment-
linked plans only
Change of Dividend Option
Option 1 – Accumulate with Interest Option 2 – Apply to Premium Option 3 – Pay In Cash
APL: Automatic Premium Loan
Change of Non-Forfeiture Option (NFO) RPU: Reduced Paid up
ETI: Extended Term Insurance
From: APL RPU ETI
To: APL RPU ETI
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Policy Change Request Form
Death Benefit Option (Applicable for Variable Life policies only)
Increasing Death Benefit Level Death Benefit
Policy Coverage Changes
Decline Index - Linked Increase Endorsement (IIE) Option Upgrade
Change of basic sum insured
Increase Decrease new total amount Php/$ ________________________________
Supplementary Benefit/Rider The Index - Linked Endorsement
option, if applicable, is your
Rider Name Add Delete Increase Decrease New total Sum Insured/Coverage
policy’s built-in protection against
inflation. For a minimum
Php/$ _____________________
incremental premium,
increase your policy’s Sum Insured.
Php/$ _____________________ No additional application, proof of
insurability or medical examination
is required when you avail of the IIE.
Php/$ _____________________
Php/$ _____________________
For activation of Index - Linked
Php/$ _____________________ Increase Endorsement Option,
reinstatement, addition or increase
of policy coverage, please
complete as well the Health
Statement form for assessment.
Term/Conversion (For policy/rider with convertible option)
Type of Conversion Term Policy Term Rider Conversion of term basic plan &
term riders require
Existing Policy Number/Rider Name _______________________________________________________ accomplishment & submission of
a new life insurance application
New sum assured to be converted Php/$ _________________________________________________
form.
Personal Particulars
Updating/Correction of Personal particular
Insured
Name
Pls. provide proof of
ID Card/Passport No
identification for changes in
personal information
Change Signature of Insured
Correct sex to Correct Date of Birth to (yyyy/mm/dd) Change Civil Status to If Change is:
Male Female Single Married Marriage
Separated Widowed (attach Marriage Contract)
Policy Owner Correction of Name
(attach Birth Certificate/Passport)
Name Annulment
(attach Annulment documents)
ID Card/Passport No
Change Signature of Policy Owner
Correct sex to Correct Date of Birth to (yyyy/mm/dd) Change Civil Status to
Male Female Single Married
Separated Widowed
Others, please specify below
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Policy Change Request Form
Certification of Customary Signature
Let’s Stay Connected!
We would like to serve you
IMPORTANT: If signature differs between AXA file and documents submitted, please complete this form. better and keep you abreast
CERTIFICATION OF CUSTOMARY SIGNATURE with news and information
about the Company and your
This is to certify that I am the same person who signed in the policy contract. I hereby confirm that the declarations
policy. Help us ensure timely
and information therein were given by me, and I certify that they are true and complete to the best of my knowledge.
delivery of our services
Finally, the signature appearing on all the forms and valid ID/s are my customary signatures and for which reason by providing us your current
I have signed both with my customary signatures as follows: contact information.
1. 2 3
Here is my updated information:
Mailing Address:
Home Business
_______________________________
Declarations and Agreement
_______________________________
I/We hereby request that my policy be changed in accordance with the particulars as indicated in this application form. _______________________________
I understand and on behalf of myself/ourselves/and all relevant persons that;
_______________________________
(1) the request for reinstatement, change or addition which requires evidence of insurability that consist of this application
and health declaration and shall not take effect unless all of the following conditions are met: _______________________________
(a) any required payment for the application is paid in full;
(b) the application is approved by AXA Philippines in its Head Office during the lifetime and continued insurability of the _______________________________
person or persons insured by the policy
(2) the request for change which does not require evidence of insurability, shall consist of this application and shall be effective Home No.:
from the date of this request unless a letter date is specifically indicated, but only if the change is provided by the policy or
is allowed by AXA Philippines under the policy; _______________________________
(3) the Incontestability Provision and Suicide Exclusion Provision in the policy shall apply upon reinstatement, changes or Office No.:
addition of sum insured or supplements and the period of time specified in the said provisions shall run from the date of
_______________________________
approval of this application by AXA Philippines;
Mobile No.:
(4) This form and the evidence of insurability of the person or persons insured if required by AXA Philippines shall be the basis
for the change in this policy and will form part of the policy unless otherwise specified.
_______________________________
I/ We HEREBY DECLARE AND AGREE on behalf of myself/ourselves/and all Relevant Persons that; Email Address:
(1) all statements and answers to all questions whether or not written by my own hand are to the best of my knowledge and
_______________________________
belief, complete and true;
(2) should any statement(s) be incomplete, false, wrong or inaccurate, or should there be any omission(s) on my/our part in YES! I would like to receive news
disclosing the information, the Company shall have the right to cancel the Policy or repudiate the claim and forfeit all from AXA via:
payments received;
Mail Email
(3) the Company is not bound by any statement which I may have made to any person if not written or printed here.
Mobile SMS Personal Call
IMPORTANT: PLEASE DO NOT SIGN ON A BLANK FORM
Signed at __________________________________ this _______day of _______________________.
Signature over printed name of Policy Owner
Signature over printed name of Assignee*, if any
Signature over printed name of Irrevocable Beneficiary*, if any
*If there is more than 1 assignee and or irrevocable beneficiary, please use this portion in indicating their
respective names and signatures.
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