INSULAR LIFE - Policyholder Services

Application for
REINSTATEMENT/POLICY CHANGE

We hereby apply for reinstatement / policy change of Policy No. ______________________
Insured Name:	______________________	Applicant-Owner's Name:	________________________
Mailing Address:	______________________	Mailing Address:	________________________
____________________________________		______________________________________________

Agent's Code:_________________ Payment: Php_________________ OR #:_________________ Date paid:_________________

Documents Enclosed: Full Medical Examination Policy Contract Others(Please specify)______________________

Present Occupation

Insured/Owner	Occupation	Nature of Work	Company Name & Address
	___________________	___________________	______________________
	___________________	___________________	______________________
	___________________	___________________	______________________
	___________________	___________________	______________________

That since the issuace of said Policy, I/we HAVE NOT: a.) received any threat on my/our life/lives; b.) been a party to any administrative/civil/criminal case; c.) made any application for life, accident or sickness insurance or for reinstatement thereof which has been declined, postponed or modified in kind, rating; and that I/we HAVE NO pending application for life insurance.
For exception/s, pls specify.________________________________________________________________________________
That within the next twelve (12) months I/We DO NOT intend to: a.) change my / our occupation/s;
b.) work or reside outside the Philippines; c.) become member/s or the Armed Forces or Police Force.
For exception/s, pls specify.________________________________________________________________________________
That I/We HAVE NOT made during the past two (2) years, NOR do I/We instend to make within the next twelve (12) months, any aerial flights other thatn that as paseenger/s on scheduled commercial airlines.
For exception/s, pls specify.________________________________________________________________________________

I/We hereby represent that each of the foregoing statements written in PART 1 of this form are true and correct and that I/We have fully stated exceptions to each of the statements and that if no exceptions are listed in the blank space provided for such exception, it shall have the same force and effect as if the word "NONE" were written therein.

I/We further agree that any payment made in connection with this application shall be considered as deposit only and shall not bind the company until this application is finally approved by the company during my/our lifetime and good health. If this application is disapproved, I/We also agree to accept the refund of all payments made, without interest. I/We understand that the statements in this application shall form part of this life Insurance contract.

DONE at _________________________________________________ this ____________________ day of __________, 20______.


______________________________	______________________________	______________________________
Signature of Witness/Agent	Signature of Payor / Applicant - Owner	Signature of Insured
______________________________	______________________________
Signature of Irrevocable Beneficiary	Signature of Assignee

NOTE: THE COMPANY MAY, AT ITS DISCRETION, DENY THIS APPLICATION OR REQUEST THAT APPLICANT/S TO FURNISH ADDITIONAL EVIDENCE OF INSURABILITY.

FOR HOME OFFICE USE ONLY

Approved by: _____________	Office: _____________	Date: _____________
HOME OFFICE ENDORSEMENT:

NO.____________________
AUTHORIZATION TO RELEASE RECORDS AND INFORMATION
To whom it may concern: I, in my personal capacity or as legal guardian of ____________________, authorize any person, insurance company, or entity to give Insular Life or its authorized representative all requested records and information of my or ______________________hospitalization, consultation or treatment in its custody, and needed as requirements for my reinstatement/policy change application and/or for any transaction involving my insurance policy. A photocopy of this authorization shall be valid as the original.
________________________________		________________________________
Printed Name and Signature of Applicant - Owner		Printed Name and Signature of Insured

REVIVAL NOTICE
_____________
Date

Dear Policyholder/s:

You will be happy to learn that your application for the reinstatement of your policy has been approved.

To assure yourself and your loved ones of continued protection under your policy, we urge you to remember your succeeding due dates so that you can pay your premiums on time.

Policy Number	Mode	Next Premium Due Date	Premium

For this particular premium, this letter serves as your Premium Notice which you can present when you make your payment.

	Very truly yours,


	Policy Changes and Conservation Section

IL-RFPC-012005 IL-RFPC-D62005-BPI