This is in connection with the application for (check appropriate box)
New Business Application
Reinstatement, Policy Change, Conversion
Group Application
Pre Need
1. General Information
Life to be Insured / Planholder (Last Name, First Name, Middle Name)
*
First Name
Middle Name
Last Name
Client No.
Application Serial No.
Policy No. (for individual Life)
Advisor Name
New Business Office
2. Amendments
The application for this policy/ pre need plan s hereby amended or corrected as indicated below. A copy of this Amendment of Application, the original of which (signed if an Amendment) is to be retained by the Company, shall be attached to and shall apply to any policy/plan issued thereon.
3. Signatures
By signing below, you hereby declare that all declaration by the life to be insured or by the planholder and by the applicant if the application includes a waiver of premium benefit, made from the time the application for the life insurance coverage was completed to the date of signing of this Amendment of Application form remain true and correct.
You hereby agree that this declaration as to your insurability and the aboe amendments will form part of the application.
Place of Signing
Date of Signing
-
Day
-
Month
Year
Date
Signature of Life to be Insured (If other than the applicant)
Printed Name of Life to be Insured
Signature of Applicant/Planholder
Printed Name of Applicant/Planholder
Signature of Witness
Printed Name of Witness
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