Policy Amendment Request Form

Corporate/Entity Policyowner PRU LIFE INSURANCE CORPORATION OF U.K.

9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
REMINDERS: 1634 Taguig City, Philippines
Please use CAPITAL LETTERS and black ink. Customer helpdesk: (632) 8683 9000, (632) 8884 8484, (632) 8887 LIFE
Tick the appropriate box to indicate your choice. within Metro Manila, 1 800 10 PRULINK for domestic toll-free
Please do not sign on a blank form. Email: [email protected] Website: www.prulifeuk.com.ph
If not applicable, put “N/A” in all empty fields.
One form for multiple policies may be used for:
• Minor amendment requests; and
• Major amendment requests if the Policyowner, Life Insured, and Irrevocable Beneficiary/ies are all the same. POLICY NUMBERS
Otherwise, the individual submission of Policy Amendment Request Form for each policy will be required.

PAC 22-000000
DETAILS OF POLICYOWNER
COMPANY/BUSINESS NAME NAME OF AUTHORIZED REPRESENTATIVE

COMPANY REGISTRATION NUMBER MOBILE NUMBER OF AUTHORIZED REPRESENTATIVE

COUNTRY OF INCORPORATION TELEPHONE NUMBER OF AUTHORIZED REPRESENTATIVE

DATE OF INCORPORATION (mm/dd/yyyy) EMAIL ADDRESS OF AUTHORIZED REPRESENTATIVE

With changes in Policyowner's details in the records of Pru Life UK? Yes (Fill out the additional KYC details section) No

DETAILS OF AMENDMENT REQUEST

MINOR AMENDMENT

1 ADDITIONAL KNOW-YOUR-CUSTOMER (KYC) DETAILS OF THE POLICYOWNER

If there are no changes in the following information, you may skip this section. Any information provided in this section will be used to update the Policyowner's details in our records.
DIRECTORS (Please attach an updated General Information Sheet for the complete list of members of the Board of Directors.)

PRINCIPAL STOCKHOLDERS OWNING AT LEAST 2% OF THE GENERAL STOCK (Please attach an updated General Information Sheet for the complete list of stockholders.)

BENEFICIAL OWNERS (Individuals owning/controlling more than 20% of the company's shares or voting rights.) Please attach an updated General Information Sheet.

SUBSTANTIAL UNITED STATES (US) BENEFICIAL OWNERS

COMPANY TELEPHONE NUMBER COMPANY MOBILE NUMBER

COMPANY EMAIL ADDRESS

NATURE OF BUSINESS a) Is the Policyowner listed or traded on any regulated stock exchange?
(If no, please complete question “b” below; otherwise, please ignore.) Yes No
1 2
Financial institution Professionally managed trust Others 3
b) Does any USA person, entity, directly or indirectly, own more than Yes No
1 Financial institution refers to any organization that holds a banking, securities, and/or life insurance license.
10% of the organization?
Examples of financial institutions include banks, life insurers, custodians, asset managers, and investment funds. 3 Defined as one of the following: a) citizen or resident of the USA; b) a partnership, corporation, company, or association
2 Professionally managed trust is a trust that is professionally managed by a bank, custodial institution, life insurance
created or organized in the USA or under the laws of the USA; c) any USA estate; d) any USA trust subject to USA
company, or investment entity that is a professional investment advisor. supervision and substantially controlled by a USA person.
BUSINESS ADDRESS ALTERNATIVE ADDRESS Tick if same as
(number, street, municipality/city, province) (number, street, municipality/city, province) business address

COUNTRY ZIP CODE COUNTRY ZIP CODE

I warrant that the consent of the Beneficial Owner/s were obtained for the use, storage and processing of their information for purposes of compliance with regulatory requirements, the processing of
the amendment applied for, and administration of the Policy/ies. I undertake to provide Pru Life UK with proof of my authority to give the required consents of the Beneficial Owner/s with respect to
the disclosure and processing of their personal information and/or sensitive personal information for the legitimate purposes set out in this Policy Amendment Request Form or in the Policy/ies.
Preferred billing address of Policyowner for Pru Life UK correspondence: Insured’s present address Business address
Insured’s permanent address Alternative business address
REASON FOR CHANGE IN ADDRESS (Note: If the new address is the same as the servicing agent’s address, please indicate the relationship with the agent and reason for such request.
This request is subject to further evaluation and approval in compliance with Pru Life UK guidelines.)

FOR OFFICIAL USE ONLY

BRANCH RECEIPT DETAILS HEAD OFFICE RECEIPT

DETAILS

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 DETAILS OF AMENDMENT REQUEST
2 CHANGE DETAILS OF LIFE INSURED
Please fill out only the fields that need to be updated/changed.

SURNAME MOBILE NUMBER TELEPHONE NUMBER

GIVEN NAME EMAIL ADDRESS

TIN SSS/GSIS
MIDDLE NAME

OTHER LEGAL NAME/ALIAS OCCUPATION (State exact duties; if member of AFP/PNP, state rank)

GENDER CIVIL STATUS SALUTATION NATURE OF WORK OR NATURE OF BUSINESS (if self-employed)
Male Single Married (e.g. Mr., Mrs., Miss, etc.)
Female Others
DATE OF BIRTH (mm/dd/yyyy) AGE NATIONALITY EMPLOYER

PLACE OF BIRTH (city/province, country)

PRESENT ADDRESS NATURE OF BUSINESS OF EMPLOYER

(number, street, municipality/city, province)

EMPLOYER’S MOBILE NUMBER EMPLOYER’S TELEPHONE NUMBER

COUNTRY ZIP CODE EMPLOYER’S EMAIL ADDRESS

PERMANENT ADDRESS Tick if same as

(number, street, municipality/city, province) present address EMPLOYER/BUSINESS ADDRESS (number, street, municipality/city, province)

COUNTRY ZIP CODE COUNTRY ZIP CODE

3 CHANGE IN BENEFICIARIES
Accomplish this section only if there are changes in the Beneficiary Details.
Pru Life UK will assume the following default options unless stated otherwise: a) Beneficiary Designation – Revocable b) % Share – equal sharing among Beneficiaries

TYPE OF SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER
REQUEST Male Female
Add
RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH NATIONALITY
Delete Primary Secondary Revocable Irrevocable
Change COUNTRY ZIP CODE
in
PRESENT ADDRESS (number, street, municipality/city, province) Tick if same as Policyowner
details

TYPE OF SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER
REQUEST Male Female
Add
RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH NATIONALITY
Delete Primary Secondary Revocable Irrevocable
Change COUNTRY ZIP CODE
in
PRESENT ADDRESS (number, street, municipality/city, province) Tick if same as Policyowner
details

TYPE OF SURNAME, GIVEN NAME, MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) GENDER
REQUEST Male Female
Add
RELATIONSHIP TO INSURED % SHARE TYPE OF BENEFICIARY BENEFICIARY DESIGNATION PLACE OF BIRTH NATIONALITY
Delete Primary Secondary Revocable Irrevocable
Change COUNTRY ZIP CODE
in
PRESENT ADDRESS (number, street, municipality/city, province) Tick if same as Policyowner
details

Please use the special instructions box below if there are more than three (3) Primary and/or Secondary Beneficiaries.
SPECIAL INSTRUCTIONS

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 DETAILS OF AMENDMENT REQUEST
4 CHANGE METHOD OF PAYMENT

Cash Post-dated check

5 RESUME CREDIT CARD/AUTO-DEBIT ARRANGEMENT (ADA) BILLING

I, as the Authorized Representative, opt to resume credit card/ADA billing and allow Pru Life UK to collect all unpaid premiums from the most recent enrolled/existing card
of the Policyowner.

6 STOP CREDIT CARD/AUTO-DEBIT ARRANGEMENT (ADA) BILLING

I, as the Authorized Representative, opt to stop credit card/ADA billing and agree to the following conditions:
Request must be received by Pru Life UK at least five (5) working days before the premium due date. All unpaid premiums shall be collected upon resumption of the billing.
To prevent lapsation of the Policy/ies, the Policyowner may select from Pru Life UK’s payment facilities.

7 CHANGE MODE OF PAYMENT

Annual Semi-annual Quarterly Monthly

8 PREMIUM HOLIDAY AVAILMENT

I, the Authorized Representative, opt to avail of the Premium Holiday. Premium payments may be discontinued at any time, as long as the fund value is sufficient to cover
the applicable charges on the Policy/ies. Once the fund value is insufficient to cover the said outstanding charges, the Policy/ies will be terminated.
If this feature is availed of, corresponding charges will be applied (applicable for Elite plans).

7
9 CHANGE MODE OFOPTION
NON-FORFEITURE PAYMENT
(FOR TRADITIONAL PLANS ONLY)

Cash surrender value Reduced paid-up insurance Automatic premium loan option Extended term insurance

10 DIVIDEND OPTION AND SUB-OPTION (FOR TRADITIONAL PLANS ONLY)

Paid in cash Used to pay a portion of premium Used to buy paid-up insurance Left to accumulate and earn
interest sub-option:
Ordinary accumulation
Self-liquidation
Fully paid-up
Early maturity
Cash allowance

11
7 CHANGE MODE
DIVIDEND CONSENT
OF PAYMENT
(FOR TRADITIONAL PLANS ONLY)

CASH
I, the Authorized Representative, agree
POSTtoDATED
use anyCHECK
dividend accumulation of the Policy/ies towards any premium default option in effect.

MAJOR AMENDMENT

12 PREMIUM

Increase Decrease Amount:

13
7 SUM ASSURED

CASH
Increase Decrease Amount:

14
7 RIDERS

TYPE OF REQUEST NAME OF RIDER RIDER COVERAGE

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Add Delete Increase coverage Decrease coverage

Please use the special instructions box below if there are more than ten (10) riders.
SPECIAL INSTRUCTIONS

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 DETAILS OF AMENDMENT
15 RECONSIDERATION OF RATING

Health Occupation
• Submission of medical documents is required. • Completely fill out the “Change in Occupation” details.
• The Policyowner will shoulder the expenses for medical examinations. • A Certificate of Employment from the Life Insured's new employer is required.
• Request is subject to the approval of Pru Life UK.

CHANGE OF OCCUPATION DETAILS

NEW OCCUPATION NATURE OF WORK OR NATURE OF BUSINESS (if self-employed)

EMPLOYER

NATURE OF BUSINESS OF EMPLOYER

EMPLOYER/BUSINESS ADDRESS (number, street, municipality/city, province) COUNTRY

ZIP CODE

JOB DESCRIPTION

SPECIAL INSTRUCTIONS

STATEMENT OF INSURABILITY
This section should be completed and signed by the Life Insured for any increase in insurance coverage, inclusion of riders, or any request involving additional risks.

Life Insured Details

1. Are you in good health, free from all diseases, deformities and abnormalities? If no, please provide details. Yes No

2. Since the issuance of the Policy/ies or the last reinstatement, have you: Details of “YES” answer
a) Ever had any illness or recurrent illness, injury, medication, or disease? Yes No

b) Ever had any medical consultation, hospitalization, or surgical operation due to any condition, or been prescribed for or
Yes No
attended by a physician or practitioner for any cause, or undergone any diagnostic test/s? Please indicate results.

c) Ever been confined or hospitalized in a clinic, institution, or other medical facility? Yes No

d) Ever changed your customary occupation, or country of residence? If yes, please indicate details. Yes No

e) Ever had any application for life, accident or health insurance, or reinstatement that was declined, postponed, rated, or
Yes No
modified?

f) Experienced death among the immediate members of your family? If yes, please provide details. Yes No

3. For female clients, are you now pregnant? If yes, how many months? Yes No

AUTHORIZATION TO FURNISH MEDICAL INFORMATION

In order to be able to process this request, the Policyowner and/or Life Insured authorize PRU LIFE INSURANCE CORPORATION OF U.K. and its authorized representatives, including its
investigators, to obtain the relevant medical information from hospitals, medical facilities, and physicians. A photocopy of this authorization shall be deemed as valid as the original.

SUBSTITUTE DECLARATION STATEMENT

✔ Tick if statement below is applicable

I, the Authorized Representative, declare that the Policyowner is not one of the following:
(a) Financial institution;
(b) Professionally managed trust;
(c) Non-listed entity of which more than 10% is owned by any USA person/entity; or
(d) Required to file a tax return in the USA.

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 DECLARATION OF UNDERSTANDING

PLEASE READ CAREFULLY BEFORE SIGNING THE POLICY AMENDMENT REQUEST FORM:
By signing this Policy Amendment Request Form (“Form”), I (i.e. each of the Policyowner/Authorized Representative, Life Insured, and the Irrevocable Beneficiary/ies, if any)
declare, agree to, and authorize the following:
 
1. All the statements and answers in this Form and any information given to Pru Life UK or its medical examiners, including any amendments, are complete, true, correct and
binding on all parties in interest under the Policy/ies.
  Pru Life UK reserves the right to request for additional medical evidence to assess my health. Any physician, hospital, clinic or medical organization is authorized to furnish
2.
Pru Life UK with any medical information pertaining to me.
  Prior to the approval of the amendment of the Policy/ies applied for, I agree to inform Pru Life UK of any change in my (a) state of health, and (b) occupation or activities.
3.
 
4. I will update Pru Life UK in a timely manner of any change in details previously provided especially with respect to a change in citizenship, tax status or tax residency. If the
Policyowner is a corporation, changes in registered address, address of place of business, substantial shareholders, legal or beneficial owners who own or control more than
20% of the Policyowner will also be disclosed. If any of these changes occurs or if any other information comes to light concerning such changes, I agree to provide additional
documents or information as may be requested by Pru Life UK, including but not limited to duly completed and/or executed (and, if necessary, notarized) tax declarations or forms.
 
5. This application is subject to the guidelines on anti-money laundering and financial underwriting. Pru Life UK can disapprove this application or terminate the Policy/ies if I fail
to provide the necessary information relating to this application or relevant transaction or if this application violates the said guidelines.
6. I fully understand and accept the consequences of the amendment requested hereunder. 
 7. I agree to receive financial and other policy related information through the mobile number and email address provided to Pru Life UK. Pru Life UK shall not be liable for claims
  or liabilities incurred as a result of the dissemination of personal information through said facilities.
8. I understand that Irrevocable Beneficiary/ies is/are given equal rights over the Policy/ies as the Policyowner. I, as the Policyowner, cannot exercise any of my rights under the
Policy/ies without the consent and signature of all Irrevocable Beneficiary/ies. Such rights include but are not limited to decrease or deletion of any benefit or the change,
  addition or deletion of beneficiaries.
9. I understand that I must submit this form within three (3) months from the date of signing.

Purpose Statement:

We will process the information you have provided in this form for the purpose of handling your request in accordance with applicable privacy laws and
regulations. During processing, we may share the information you provided to our authorized data processors, including couriers and contractors for anti-money
laundering systems, photocopying, scanning, indexing and printing services. We may share your information with governmental and other regulatory authorities,
or self-regulatory bodies in various jurisdictions as required or allowed by applicable laws and regulations. Any information collected may be retained by Pru Life
UK and our authorized data processors until ten (10) years from the date of termination of the policy.

You may revisit our privacy policy through our website at (https://www.prulifeuk.com.ph/en/footer/privacy-policy/). For data privacy concerns, please contact our
Data Privacy Officer at:

Telephone: (632) 8887 5433 for Metro Manila, 1 800 10 7785465 via PLDT landline for domestic toll-free
Email: [email protected]

(mm/dd/yyyy)
EXECUTED AT THIS
PLACE

Signature over printed name of POLICYOWNER/AUTHORIZED REPRESENTATIVE Signature over printed name of WITNESS

Signature over printed name of LIFE INSURED Signature over printed name of IRREVOCABLE BENEFICIARY/IES/ASSIGNEE

Signature over printed name of IRREVOCABLE BENEFICIARY/IES/ASSIGNEE Signature over printed name of IRREVOCABLE BENEFICIARY/IES/ASSIGNEE

CERTIFICATION OF CUSTOMARY SIGNATURE FOR POLICYOWNER/AUTHORIZED REPRESENTATIVE

This is to certify that I am the same person who signed the

Application for Life Insurance. I confirm that the declarations
and information therein were given by me personally and that
they are true and complete to the best of my knowledge.

Finally, I certify that the signature appearing on all my forms

and valid IDs is my customary signature, as follows:

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CERTIFICATION OF CUSTOMARY SIGNATURE FOR IRREVOCABLE BENEFICIARY/IES

Full name of Irrevocable Beneficiary 1:

Full name of Irrevocable Beneficiary 2:

Full name of Irrevocable Beneficiary 3:

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