CCLPI

COSMOPOLITAN CLIMBS LIFE PLAN INC.

4/F CLIMBS Bldg., Tiano-Pacana Sts., Cagayan de Oro City
Tel. No: (088) 880-1574; Hotline No: +63 917 154 3459 / +63 998 953 4937

Plans Email Address: cclpi.preneed@cclpi.com.ph; website: cclpi.com.ph

APPLICATION FOR ANGELICA LIFE PLAN REINSTATEMENT

I hereby apply for reinstatement of the Angelica Life Plan Agreement contracted with you is now on lapse
status. Hereunder are the necessary information:

PLANHOLDER ________________________________________________ LIFE PLAN NO. ________________

ADDRESS ___________________________________________________________________________________

HEALTH DECLARATION
I hereby represent and declare to the best of my knowledge that:
a. I am in good health.
b. I am not more than 65 years of age at my nearest birthday.
c. In the event I am not an elgible for insurance coverage under the Company’s Group Credit
Life and Yearly Renewable Term Insurance Policies, the Angelica Life Plan Agreement
continues with No Insurance Benefit (NIB).
d. I have not been confined in any hospital, sanitarium or infirmary, nor received medical or
surgical treatment for heart condition, high blood pressure, cancer, diabetis, lung, kidney
or stomach disorder or any physical impairment since the date of issuance of my policy.
Exceptions:_______________________________________________________________________________
I agree that if no exception is listed in the blank space provided, this shall have the same force and
effect as if the word “NONE” was written therein.

PAYMENT METHOD :
Updating ______(payment of all unpaid premiums);
Re-dating ______(payment of 1premium)*maturity & 5%increment will be moved
PAYMENTS MADE :
Installment premiums of : P_____________________O.R.#/Date_________________
Equivalent ______A/SA/Q/M
Surcharges ______________________x2% : _____________________ O.R.#/Date________________
Reinstatement Fee : _____________________ O.R.#/Date________________
Finance Charges _______________x8% : _____________________ O.R.#/Date________________
TOTAL PAYMENT : ______________________

It is agreed that subject Angelica Life Plan Agreement shall be considered reinstated only upon
approval by the Company at its Head Office and upon satisfaction of all other Company requirements. This
Application shall form part of the Life Plan No._________. Furthermore, it is understood that any payment made
or to be made in connection with this application shall first be considered as deposit and will not bind the
Company until its approval.

I hereby certify that all the above data are true and correct and any erroneous or untruthful statement
shall not subject CCLPI to any liability whatsoever for any consequence arising therefrom.

Done this __________ day of ________________________, 20_____ at ______________________________________________.

___________________________________________________ ______________________________________________
Reinstating / Sales Counselor Planholder Printed Name & Signature

Verified by :________________________________

***************************************************************************************************
FOR HEAD OFFICE USE ONLY (ACCT & CLAIMS DEPT)
1. New effectivity Date __________________________________ (contestability period will start again)
2. Date of Endorsement _________________________________

Processed by :___________________________________________________
PRINTED NAME & SIGNATURE