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Insurance Application Amendment

The document is an amendment application for Pru Life Insurance Corporation of U.K. by Miss Interone Illone Brae and Miss Interone Aileen Maslog. It includes a declaration of insurability confirming that the life insured is in good health and has no pending insurance applications. The amendment specifies that the middle name is not applicable for the life insured and is binding on all parties involved.

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82 views1 page

Insurance Application Amendment

The document is an amendment application for Pru Life Insurance Corporation of U.K. by Miss Interone Illone Brae and Miss Interone Aileen Maslog. It includes a declaration of insurability confirming that the life insured is in good health and has no pending insurance applications. The amendment specifies that the middle name is not applicable for the life insured and is binding on all parties involved.

Uploaded by

unit3koperations
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Application # 25321393

Agent # 70159858

AMENDMENT OF APPLICATION
Mr/Mrs/Miss/Title Life Assured (Last name, First name, Middle name)
Miss Interone Illone Brae

Mr/Mrs/Miss/Title Applicant (Last name, First name, Middle name)


Miss Interone Aileen Maslog

I/We hereby apply the following amendments to Pru Life Insurance Corporation of U.K.:
FROM TO
MDDLE NAME NOT APPLICABLE MIDDLE NAME NOT APPLICABLE

DECLARATION OF INSURABILITY
Since the date of the original application, the Proposed Life Insured or the Applicant (if other than
the Proposed Life Insured)
(a) has continued in good health;
(b) has not made an application for insurance which has been declined, postponed or modified;
(c) has no other application for insurance pending in any other company at the present time;
(d) has not consulted or been examined by a physician or practitioner and;
(e) his insurability as a life insurance risk has not been changed by any event or circumstances.
If there are any exceptions to any of the above statements, give full details in the space provided.

The Policy Life Insured has no Middle Name

The Proposed Life Insured or the Applicant (if other than the Proposed Life Insured) represent that
the above statements are true and complete and that all exceptions have been stated.
The Proposed Life Insured or the Applicant (if other than the Proposed Life Insured) further agrees
that the above changes shall be an amendment to and form a part of the original application and
of the policy issued thereunder, if any, and that they shall be binding on any person who shall
have or claim any interest under such policy.
El Salvador City 22nd January 25
Dated at _________________________ this _____ day of ____________________, 20 ______.

Julie Ann Interone Diango Illone Brae Interone

Signature over Printed Name of WITNESS Signature over Printed Name of LIFE INSURED

Klient Christian Roger D. Palconet Aileen Maslog Interone

Signature over Printed Name of WITNESS Signature over Printed Name of APPLICANT

NB-AOA-0602

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