Change of Life Assured Form 70000981
Change of Life Assured Form 70000981
Tick the required boxes, fill in the details and sign next to any amendments made.
Addition (Complete All) Deletion (Complete 1 to 3) Addition (Complete All) Deletion (Complete 1 to 3)
1. Full Name (According to NRIC/Passport/BC) – Please underline 1. Full Name (According to NRIC/Passport/BC) – Please underline
surname: surname:
Mr Miss Madam DR Mr Miss Madam DR
4. Nationality: 4. Nationality:
6. Have you smoked any cigarettes in the past 12 months: 6. Have you smoked any cigarettes in the past 12 months:
Yes No Yes No
7. Marital Status: Single Married Divorced Widowed 7. Marital Status: Single Married Divorced Widowed
8. Occupation: 8. Occupation:
Child Spouse Others (Please specify): Child Spouse Others (Please specify):
________________________ ________________________
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Were you advised by a Financial Consultant to effect any of the alteration in Section 2? (*Please tick [ ])
If “yes”, please ask your Financial Consultant to complete the “Financial Consultant’s Acknowledgement” below. Yes No
Date (dd/mm/yyyy):
1. Does the combined coverage of your existing and pending life insurance policy(ies) exceed $500,000?
2. Do you have any application for or reinstatement of your life, critical illness, disability or health insurance
policy pending or has it been withdrawn, deferred, declined or accepted at special rates or terms with this
or any other office?
3. Are you making or have you made any claims, including hospitalisation claims, on any policy with this or any
other office?
4. Is this proposal intended to exercise conversion or increasibility option on any policy(ies) listed below?
5. Is this proposal to replace or intended to replace any policy(ies) with this or any other office?
Warning - It is usually disadvantageous to replace an existing insurance policy with a new one.
Some disadvantages are:
1) You may not be insurable on standard terms;
2) You may have to pay a higher premium in view of higher age;
3) This may result in losing the financial benefit accumulated over the years;
4) Other terms and conditions may differ.
Warning - In your own interest, we advise that you consult your present insurer before making a final
decision.Hear from both sides and make a careful comparison. You can then be sure that you are making a
decision in your best interests.
1. Aside from studies or leisure, do you plan to travel abroad for more than 6 months in the next 12 months?
If “yes”, please provide details below.
Name of Country and City Duration Purpose of Travel (Work/Military Training/ Others, please specify
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2. Are you currently engaged in or have any intention of engaging in military or private flying other than as a
fare-paying passenger or engaging in hazardous sports such as scuba diving, mountain or rock climbing,
parachuting or sky diving, any form of racing or any other extreme sports?
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3. Do you consume alcohol?
3. Have you undergone predictive genetic tests on Huntington’s Disease (HTT); breast cancer (BRCA 1, BRCA
2); or in the past 5 years, have you had any tests done such as X-ray, ultrasound, CT scan, biopsy,
electrocardiogram (ECG), blood or urine test?
4. Have you ever had or been told to have or been treated for:-
a. Epilepsy, fits, stroke, paralysis, weakness of limb, prolonged headache, unconsciousness, nervous
breakdown, depression or any other nervous/mental disorders?
b. Diabetes, thyroid disorders or any other endocrine disorders?
c. Ear discharge, nose bleeds, double vision, impaired sight, hearing or speech or any other disorders of
ear, eye, nose or throat?
d. Asthma, bronchitis, persistent cough, coughing with blood, pneumonia, tuberculosis, chest or breathing
complaints/discomfort or any other lung disorders?
e. Raised cholesterol, high blood pressure, heart attack, heart murmur, mitral valve prolapse or other heart
valve disorders, breathlessness, irregular or fast heart rate, chest discomfort or pain, diseases of or any
other disorders of the heart or blood vessels?
f. Gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach or bowel disorders?
g. Jaundice, abnormal liver function test, Hepatitis B carrier or any form of hepatitis, liver disorders or gall
bladder disorders?
h. Blood, protein or sugar in urine, kidney stones, infection or any other disorders of the kidney, bladder or
urogenital organs?
i. Slipped disc, gout, any form of arthritis, osteoporosis (weak bones), or any other disorder, pain or injury
to the muscles?
j. Cancer, tumour, cyst, lump or growth of any kind?
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m. Any other illness, disorder, injury, disability, operation or hospitalisation not mentioned above?
5. Have you or your spouse (if applicable) been told to have, or have received any medical advice, counselling
or treatment in connection with sexually transmitted disease, AIDS, AIDS Related Complex or any other AIDS
related condition?
6. Have you ever had HIV testing done for purposes other than pregnancy testing, Singapore PR application
and SAF overseas military training?
7. Have you in the last 3 months had any of the following symptoms for more than one week continuously:
fatigue, weight loss, diarrhoea, enlarged nodes or unusual skins lesions?
8. Have you been told to repeat Pap smear within the next six months or ever had an abnormal Pap smear,
mammogram, ultrasound of the pelvis or breasts, biopsy, colposcopy or any other gynaecological
investigations?
9. For females who have conceived or are currently pregnant (if not applicable, please indicate ‘N/A’)
Have you ever had:-
a. any complications during gestation or childbirth (eg. gestational diabetes, hypertension, protein in
urine, etc.)?
b. Given birth to a baby with Down’s syndrome or any other congenital anomalies?
(Only applicable if PruSmart Lady Rider is attached)
c. Any test or intend to do any test to exclude Down’s syndrome or any congenital anomalies of the baby
during gestation?
(Only applicable if PruSmart Lady Rider is attached)
10. Are you now pregnant? If yes, how many weeks? __________________
11. Have you ever had or been told to have or been treated or intend to be treated or consult a physician for:-
a. Any disease or disorder of the breasts including breast lump, cyst, fibrocystic disease, mammary
dysplasia, carcinoma in situ, cancer or growth?
b. Any disease or disorder of the cervix uteri, uterus, ovaries, vulva or fallopian tubes including ovarian
cysts, abnormal uterine or vaginal bleeding, fibroid, polyp, carcinoma in situ, cancer or growth?
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Section 3D : Declarations
Please read carefully before signing the Application for Change of Life Assured form:
email address and mobile number and/or (ii) notify Prudential of any ”Product Highlights Sheet” (where applicable),
change(s) to my/our email address and mobile number. I/We acknowledge – “Your Guide to Life Insurance” and/or “Your Guide to Health
and accept that my/our Policy Document and/ or Correspondences will be Insurance” and the contents have been explained to me/us to my/our
delivered via post if my/our email address and mobile number are not satisfaction.
provided in this proposal.
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10) Singapore Policy telephone numbers, tax status, tax identification numbers, tax residency
I/We understand that the policy applied for herein shall be underwritten as a changes or details concerning my/our policy) to any Authority for the
Singapore policy and be entered in the register of Singapore policies of purpose of compliance with or adherence (whether voluntary or otherwise)
Prudential. to or otherwise in connection with the Applicable Requirements (“the
11) Bankruptcy Purpose”) and/or I/we will be deemed to so consent when I/we provide
I/We further declare that I/we am/are not an undischarged bankrupt and that Prudential, its officers, employees and agents, from time to time, with
I/we have committed no act of bankruptcy within the last twelve months and my/our particulars or any information when having been informed herein
that no receiving order or adjudication in bankruptcy has been made against that my/our particulars or any information I/we provide may be collected,
me/us during that period. used and disclosed for the Purpose. Such disclosure may be effected by
12) Currency Conversions Prudential directly or sent and/or disclosed through any of its Head
I/We understand that for a non Singapore-dollar policy, the Singapore-dollar Office(s) or other related corporations or in such manner as it deems fit. For
return will depend on prevailing exchange rates which may be highly volatile. the purposes of the foregoing and notwithstanding any other provision in
Prudential does not bear the loss resulting from any currency conversion or the this proposal form or any other agreements between us, Prudential may
cost of charges incurred on any transaction pertaining to currency conversions. need me/us to provide further information as may be required for
13) Breach of Applicable Local Laws disclosure to any Authority and it may request that I/we provide the same
I/We understand that if I/we do not hold Singapore citizenship status, it is to it within such time as may be reasonably required.
my/our sole responsibility to ensure that, by completing and submitting this (c) Updating of Information
Change of Life Assured form, I/we will not breach or violate any of the I/We agree to update Prudential in a timely manner of any change of any
applicable local laws and regulations of the jurisdiction of the country of detail previously provided to Prudential whether at time of application or at
my/our nationality (the “Applicable Local Laws”). I/We hereby fully indemnify any other times. In particular, it is very important that I/we notify Prudential
and hold harmless Prudential and its officers, employees and agents against all immediately if, where I/we are individuals, my/our nationality, addresses,
losses, damages, civil penalties and expenses (including but not limited to legal telephone numbers, tax status, tax identification numbers, tax residency or
expenses on a solicitor-client basis) that may be suffered by any of them in personal identification numbers change or if I/we become tax resident in
connection with any breach or violation on my/our part of the Applicable Local more than one country, or, where we are a corporation or any other type
Laws. of entity, if our registered address, address of our place of business,
14) Authority to Collect, Use and Disclose substantial shareholders, legal and beneficial owners or controllers (who
I/We expressly authorise and consent to Prudential, its officers, employees and own or control more than 25% of our shares or ownership interest or
agents collecting, using and disclosing, at their sole discretion, any and all control), tax status, tax residency changes or if I/we become tax resident in
information relating to me/us, including my/our personal particulars, my/our more than one country. If any of these changes occurs or if any other
transactions and dealings and my/our policy or policies of insurance with information comes to light concerning such changes, Prudential may
Prudential, to any of the following persons, whether in Singapore or elsewhere: request certain documents or information from me/us. Such information
(a) Prudential’s holding companies, branches, representative offices, and documents include but are not limited to duly completed and/or
subsidiaries, related corporations or affiliates; executed (and, if necessary, notarized) tax declarations or forms or
(b) any of Prudential’s contractors or third party service providers or self-certifications.
distribution partners or professional advisers or agents; (d) Assistance to Prudential
(c) any regulatory, supervisory or other authority, court of law, tribunal or Notwithstanding any other provision in this Change of Life Assured form
person, in any jurisdiction, where such disclosure is required by law, form or any other agreements between us, I/we agree to provide
regulation, judgment or order of court or order of any tribunal or as a Prudential with such assistance as may be necessary to enable it to comply
matter of practice; with its obligations under all Applicable Requirements concerning me/us
(d) any actual or potential assignee(s) or transferee(s) of any rights and or my/our policies with Prudential.
obligations of Prudential under or relating to my/our policy or policies for (e) Consequences of Failure to Report Information
any purpose connected with the proposed assignment or transfer; and If I/we do not provide or update Prudential with the information or
(e) any credit bureau, insurer or financial adviser, for the purposes of documents requested in a timely manner or if any information or
underwriting, customer servicing, statistical analysis, investigation of documents provided are not up-to-date, accurate or complete, I/we agree
Prudential’s representatives, monitoring undesirable sales practices, that some or all of the benefits under the policy of assurance may not be
conducting customer due diligence, reporting to regulatory or supervisory available to me/us. In particular, I/we consent to and agree that Prudential
authorities and for auditing. may, in order to ensure its ongoing compliance or adherence (whether
Where any personal data (“3rd Party Personal Data”) relating to another voluntary or otherwise) with the Applicable Requirements, and to the
person (“Individual”) (e.g. insured persons, family members, and extent permitted by law, terminate the policy and/or withhold payment of
beneficiaries) is disclosed by me/us, I/we represent and warrant that I/we have any amount due to me/us (or my/our personal representatives) under
obtained the consent of the Individual for Prudential, its officers, employees my/our policy as may be reasonably necessary to comply with the
and representative(s) to collect and use the 3rd Party Personal Data and to Applicable Requirements and/ or deduct such amount from any policy
disclose the 3rd Party Personal Data to the persons enumerated above, whether moneys payable to me/us and/or pay the same to any relevant Authority as
in Singapore or elsewhere, for the purposes stated above and in Prudential’s the relevant Authority or Applicable Requirements may require.
Privacy Notice. (f) Account Holder
15) No Tax Advice I/we certify that I/we are the Account Holder(s) (or am authorized to sign
I/We will obtain my/our own advice on the tax implications and/or any other for the Account Holder(s) of all the accounts to which this form relates.
ancillary implications in respect of the application for this policy. I/We 17) Prohibited Person
acknowledge that Prudential and/or its representatives do not make any I understand and agree that Prudential is entitled not to accept or process this
representations and cannot assume any responsibility in respect of these Proposal should a person connected with this Change of Life Assured form be
matters. found to be a Prohibited Person, meaning a person or entity (including but not
16) Other Requirements limited to any director or direct/indirect shareholder or person having executive
(a) Applicable Requirements including Foreign Account Tax authority or natural persons appointed to act on my behalf, beneficiaries or my
Compliance Act (FATCA) and OECD Common Reporting Standard Beneficial Owner(s) or beneficiaries’ Beneficial Owner(s) therein) subject to any
for Automatic Exchange of Financial Account Information (CRS) laws, regulations and/or sanctions administered by any regulatory authorities in
I/We acknowledge that Prudential may be obliged to comply with or choose to any country, which have the effect of prohibiting Prudential from providing
have regard to, observe or fulfil the laws, regulations, orders, guidelines, codes, insurance coverage, transacting business with or otherwise offering any
market standards, good practices, requests, requirements, or expectations of or economic benefits to me or any other beneficiaries or assignees under the
agreements with public, judicial, taxation, governmental and other regulatory relevant Policy, and the decision of Prudential shall be final. I further agree that
authorities or self-regulatory bodies in various jurisdictions (the “Authorities” in the event that Prudential becomes aware that a person connected with the
and each an “Authority”) as promulgated and amended from time to time policy that is issued based on this application (the “relevant Policy”)
(the “Applicable Requirements”). These Applicable Requirements include (including but not limited to any of the Assured, trustee, assignee, Beneficiary,
but are not limited to FATCA which the United States Internal Revenue Service Beneficial Owner, or nominee) is or has become a Prohibited Person, Prudential
has promulgated and the CRS. In this connection, I/we agree that Prudential may block and/or terminate the (i) coverage of that Insured, and/or (ii) relevant
may disclose my/our personal information (which shall include but are not Policy, with immediate effect, and shall not thereafter be required to transact
limited to my/our nationality, date and place of birth, addresses, telephone any business with any person connected with the relevant Policy in connection
numbers, tax status, tax identification numbers, tax residency changes or policy with the relevant Policy, including but not limited to, making or receiving any
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details) to any Authority and withhold payments otherwise payable to me/us payments under the relevant Policy. I also agree (as an ongoing obligation) to
under my/our policy as may be reasonably necessary to ensure Prudential’s notify Prudential in writing immediately of any change(s) to the identities,
compliance or adherence (whether voluntary otherwise) with the Applicable status/constitution/establishment, particulars and identification documents of a
Requirements. person connected with the relevant Policy. If an application is accepted or
(b) Consent to Collection, Use and Disclosure in relation to Applicable processed by Prudential despite a person connected with the relevant Policy
Requirements being a Prohibited Person, Prudential shall be entitled to block and/or terminate
I/We hereby consent to Prudential’s, its officers’, employees’ and agents’, the relevant Policy at any time, whether with effect from inception of the
collection, use and disclosure of my/our particulars or any information relevant Policy or otherwise.
(which shall include my/our nationality, date and place of birth, addresses,
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Please note that our decision and acceptance of the proposal in your Life Assured form has been made based on the information that you have provided to
us in your Life Assured form. In the event that you decide to submit a New Business Supplementary Form containing information which was not provided
or disclosed in your Life Assured form, our decision shall be automatically revoked and deemed void and we shall consider your proposal anew based on the
fresh information that you have provided in the New Business Supplementary Form read together with the information previously submitted by you in your
Life Assured form.
If a material fact is not disclosed in this proposal, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to
disclose it. This includes any information that you may have provided to the Financial Consultant but was not included in the proposal. Please check to
ensure you are fully satisfied with the information declared in this proposal.
By signing below, I/we confirm that I/we have read, understood, consent to and confirm the contents of the Declarations in this form, in
particular, the sections of the Declarations referring to “Consent to Collection, Use and Disclosure in Relation to Applicable Requirements”
and “Consequences of Failure to Report Information”.
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Additional Information by Financial Consultant
Please tick boxes ( ) where applicable and provide the relevant details
Is there any concurrent new proposal/reinstatement/Mid Term Addition? Yes No
If yes, please state proposal/policy no(s) :
Does this application qualify for any campaign or discount program by Prudential? (Applicable to selected plans only) Yes No
If yes, please state campaign type :
Is there any additional information that you wish to inform Prudential about this proposal/policy? Yes No
If yes, please provide the information.
L2AFCR
L2AFCR