Scribd
Upload
103 views1 page

Amendment Form New

This document is a request for amendments to a specific insurance policy, detailing the requested changes and authorizing the corporation to correct any errors. It includes spaces for signatures of the life insured, policy owner, irrevocable beneficiaries, and a witness. The request must be dated and is considered an application for the amendment of the policy.

Uploaded by

Iris
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
103 views1 page

Amendment Form New

This document is a request for amendments to a specific insurance policy, detailing the requested changes and authorizing the corporation to correct any errors. It includes spaces for signatures of the life insured, policy owner, irrevocable beneficiaries, and a witness. The request must be dated and is considered an application for the amendment of the policy.

Uploaded by

Iris
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

REQUEST FOR AMENDMENT OF POLICY

Please make the following amendment/s in POLICY NUMBER ___

REQUESTED AMENDMENT/S:

FOR HOME OFFICE CORRECTIONS and/or ADDITIONS only:

This request together with the original application and statements made to the
Corporation for the above numbered policy heretofore issued shall be for all purposes
taken and considered as the application for the amendment of the above numbered
policy.

In case of apparent errors or omissions discovered by the Corporation in the foregoing


request, we hereby authorize the Corporation to correct or complete this request for
amendment of policy and we agree that if the policy is changed in accordance with such
amended request, our acceptance of any policy so amended or re-issued will constitute
our conformity to any correction in or addition to this request made by the Corporation in
the space provided for “HOME OFFICE CORRECTIONS AND/OR ADDITIONS”

Dated at _______________ this ______ day of ___________20___.

_______________________________ _ __ __________
Printed Name & Signature of Life Insured Printed Name & Signature of Owner
(if other than Life Insured)

__________________________________ ______________________________________
Printed Name & Signature of Irrevocable Printed Name & Signature of witness
Beneficiary/ies

You might also like