Request for Change Form - AXA Life Insurance Singapore
Request for Change Form - AXA Life Insurance Singapore
Request for Change Form - AXA Life Insurance Singapore
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REQUEST FOR CHANGE*ROCX*Policy Number : Date :Assured / Trustee / Assignee : NRIC No :I request that the following change(s) be made to the policy(ies). I understand that the alteration(s) will not be effective until I receivean official letter from <strong>AXA</strong> <strong>Life</strong> confirming the change(s).A. Personal <strong>Change</strong>s<strong>Change</strong> Name or NRIC No. of *Assured / <strong>Life</strong> Assuredto<strong>Change</strong> of Address / Telephone nos.(Note : Please attach documentary proof <strong>for</strong>changes)<strong>Change</strong> of Citizenship toPostal Code(Note : Please attach documentary proof <strong>for</strong>changes)<strong>Change</strong> of SignatureOld SignatureNew SignatureTelephone Nos.Email Address(O)(R)(HP/P)B. Payment <strong>Change</strong>s<strong>Change</strong> Mode(Please tick option and use Giro <strong>for</strong> ‘Monthly’ mode) Annual Quarterly Semi-Annual MonthlyAdvance Premium Payment of $_<strong>for</strong>instalments*(Annual / Semi-Annual / Quarterly / Monthly)Standing Order to Deposit Future Cash Advances<strong>Change</strong> Method(Please fill in the DDA <strong>for</strong>m <strong>for</strong> payment through Giro) Cash / Cheque Giro<strong>Change</strong> Bank(Please fill in a fresh DDA <strong>for</strong>m)Cancellation of Standing Order to Deposit Future CashAdvances<strong>Change</strong> Amex credit card number(For policies previously sold under AMEX)New Credit Card number : ____________________Card expiry date : ___________________________C. Policy <strong>Change</strong>s*Reduction / Increase of Sum Assured <strong>for</strong>(Please attach Health Declaration <strong>for</strong>m <strong>for</strong> increase ofSum assured – terms apply) Basic PolicyFrom $To $ Riders / Benefit(Please specify rider / benefit name)From $To $<strong>AXA</strong> <strong>Life</strong> <strong>Insurance</strong> <strong>Singapore</strong> Pte Ltd (Company Reg. No. 199903512M)8 Shenton Way #27-02 <strong>AXA</strong> Tower <strong>Singapore</strong> 068811<strong>AXA</strong> Customer Centre #B1-01 Tel: 6880 5500 Fax: 6880 5501Website: www.axalife.com.sg*Delete whichever inapplicable. Page 1 of 2
C. Policy <strong>Change</strong>s (cont)*Reduction / Increase of Premium Amount(Please attach Health Declaration <strong>for</strong>m <strong>for</strong> increase ofpremium amount – terms apply)From $To $Cancellation of Rider / Supplementary Benefits(Please specify rider / benefit name)Inclusion of Rider / Supplementary Benefits(Please attach Health Declaration <strong>for</strong>m <strong>for</strong> Inclusionof rider/benefit)Benefit NameSum AssuredInclusion / Termination of Member(s)(Please attach Health Declaration <strong>for</strong>m <strong>for</strong> Inclusion ofmember(s))Member Name(s)<strong>Change</strong> Commencement date to ________________Cancel Bonus Utilization Scheme (BUS)Cancellation of Policy (WEF) ______ _(DD/MM/YYYY)*Activation / Cancellation of Indexation OptionWithdrawal of Future Premium Deposit (FPD)D. Other <strong>Change</strong>sConversion of policy to Paid-Up Assurance(all attaching riders and supplementary benefits, ifany, will be terminated)Commence Premium Holiday (ILP RP policies)From _________________ to _________________Conversion of *policy / rider of(Please specify policy / rider name)<strong>for</strong> the sum assured of $ _to a new policy. (Please attach new proposal <strong>for</strong>m)Stop Premium Holiday (Choose one of the options):Option (1) Stop Premium Holiday on from last Premium Due(Paid To Date) _______________ ___ (DD/MM/YYYY)Option (2) Stop Premium Holiday on current Premium Due DateReview of *Occupational / Health Extra__(Please specify type of extra and attach HealthDeclaration or any supporting documents)______ ________________________Others (please specify)(DD/MM/YYYY)______________________________________________________________________________________________________________________DECLARATION AND AUTHORISATION1. For <strong>Change</strong> of Address request, I/We hereby declare that the address given is not that of my financial adviser.Dated this day of (month) (year)Signature of Assured / Trustee/ AssigneeNRIC No.Adviser Name :Contact Numbers : HPOfficeSignature of <strong>Life</strong> Assured(if other than Assured)Organisation Name :*Delete whichever inapplicable.RC FORM / MAR 12 Page 2 of 2
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