NTUC Income Insurance Co-operative Limited NTUC Income Centre 75 Bras Basah Road Singapore 189557 Tel: 63 INCOME

/6788 1777 | Fax: 6338 1500 Email: csquery@income.com.sg | Website: www.income.com.sg

STATEMENT PURSUANT TO SECTION 25(5) OF INSURANCE ACT, CAP.142 (OR ANY SUBSEQUENT AMENDMENTS THEREOF) You must disclose all facts as you know or ought to know which may affect the insurance cover being applied for. Otherwise, the insurance policy issued may not be valid. Instructions on how to complete this form 1. SECTION A: Please fill in all the details. 2. SECTION B: Specify the person(s) (Dependents, including Policyholder) that you wish to apply the change(s) to. 3. SECTION C: Please fill in all the details. Important Points 1. 2. 3. 4. 5. 6. For change of payer/payment mode, please complete the “Payment Alteration Form”. For upgrade of plan/rider, please complete the application form for upgrading the plan or adding riders. Form to be received by Group & Health department at least 2 weeks prior to renewal, failing which the change may not be reflected in the renewal. If you have more than one policy and the change requested is not the same for all policies, please fill in a separate form for each policy. For any Downgrade request, NTUC Income will issue a new policy. Contact No. and/or email written under Section A is meant for verification purpose (if required).

Section A – Particulars of Policyholder (Compulsory)
Name (as shown in NRIC/FIN) Contact Number (H) NRIC/FIN Number Email: (Hp) (O) Date of birth (dd/mm/yyyy)

Section B – Persons Including Policyholder and/or Dependents Affected By This Change (Compulsory)
Policy Number Name of Insured NRIC/FIN/BC Number Relationship

Section C – Changes to the Policies stipulated under Section B (Compulsory)
Downgrade (Please tick accordingly) 1. Main Plan to:


Plan B:



Plan C:



(SG – Singaporean; PR – Permanent Resident)

Declaration and Authorisation (Compulsory)
Agreement I wish to change the above Policy according to the request(s) indicated in Section C of this form. I have read and agreed to the Important Points. I declare that the information stated by me in this form is true, correct and complete. I also understand and agree that the changes a. are subject to NTUC Income’s acceptance; b. if accepted, may be subject to terms, conditions and exclusions imposed by NTUC Income; c. will take effect only when NTUC Income accepts and approves my/our request(s) and notifies me/us in writing of the effective date of the change, provided I/we have paid the premium in full; and the Policy issued and delivered to me. d. where applicable, if my request for downgrade of my Main Plan is approved by NTUC Income, I understand, agree and accept that any Special Term which is imposed by NTUC Income on my existing Main Plan shall similarly be applicable and imposed on my new downgraded Main Plan.

Signature of Policyholder Date (dd/mm/yyyy)
NTUCINCOME/GH/PA_M/01/2013 • Page 1 of 1