DECLARATION OF UNDERSTANDING
PLEASE READ CAREFULLY BEFORE SIGNING THIS REINSTATEMENT FORM:
(
mm/dd/yyyy)
EXECUTED AT THIS
PLACE DATE COMPLETED
Signature over printed name of LIFE INSURED Signature over printed name of POLICYOWNER (If other than Life Insured)
Signature over printed name of WITNESS
By signing this Reinstatement Form ("Form"), I, (i.e. each of the Policyowner and Life Insured) declare, agree to, and authorize the following:
1. All the statements and answers in this Reinstatement Form and any information given to Pru Life UK or its medical examiners, including any amendments, are complete, true, correct,
and binding on all parties in interest under the Policy/ies.
2. Pru Life UK reserves the right to request for additional medical evidence to assess my health. Any physician, hospital, clinic, or medical organization is authorized to furnish
Pru Life UK with any medical information pertaining to me.
3. Prior to the approval of the reinstatement applied for, I agree to inform Pru Life UK of any changes in my (a) state of health, and (b) occupation or activities.
4. If a material fact is not disclosed in this Reinstatement Form, the reinstatement may not be valid. I understand that if in doubt as to whether a fact is material, it will be disclosed
to Pru Life UK.
5. The insurance coverage will not commence until the reinstatement has been approved, and the Policy/ies has been issued while I am in good health.
6. I will update Pru Life UK in a timely manner of any change in details previously provided especially with respect to a change in citizenship, tax status or tax residency. If the
Policyowner is a corporation, changes in registered address, address of place of business, substantial shareholders, legal or beneficial owners who own or control more than 25% of
the Policyowner will also be disclosed. If any of these changes occurs or if any other information comes to light concerning such changes, I agree to provide additional documents or
information as may be requested by Pru Life UK, including but not limited to duly completed and/or executed (and, if necessary, notarized) tax declarations or forms.
7. This reinstatement is subject to the guidelines on anti-money laundering and financial underwriting. Pru Life UK can disapprove this reinstatement or terminate the Policy/ies if I fail
to provide the necessary information relating to the application or relevant transaction or if the reinstatement violates the said guidelines.
8. I accept, agree with, and understand the features, benefits, nature, limitations, exclusions, risks, terms and conditions of the Policy/ies, product and attached riders. For unit-linked
products, the next computed unit price following the Reinstatement Date of the Policy/ies will be applied.
9. I agree to receive financial and other policy-related information through the mobile number and email address provided to Pru Life UK. Pru Life UK shall not be liable for claims
or liabilities incurred as a result of the dissemination of personal information through the said facilities.
AUTHORIZATION TO FURNISH MEDICAL INFORMATION
In order to be able to process this request, the Policyowner and/or Life Insured authorize PRU LIFE INSURANCE CORPORATION OF U.K. and its authorized representatives, including its
investigators, to obtain the relevant medical information from hospitals, medical facilities, and physicians. A photocopy of this authorization shall be deemed as valid as the original.
This is to certify that I am the same person who signed the
Application for Life Insurance. I confirm that the declarations
and information therein were given by me personally and that
they are true and complete to the best of my knowledge. Finally,
I certify that the signature appearing on all my forms and
valid IDs is my customary signature, as follows:
CERTIFICATION OF CUSTOMARY SIGNATURE FOR POLICYOWNER
ADDITIONAL KNOW-YOUR-CUSTOMER (KYC) DETAILS OF THE POLICYOWNER (If there are no changes in the following information, you may skip this section.)
ANY INFORMATION PROVIDED IN THIS SECTION WILL BE USED TO UPDATE YOUR PERSONAL DETAILS IN OUR RECORDS
AGE PLACE OF BIRTH
(city/province, country)SALUTATION (e.g. Mr., Mrs., Miss, etc.)
TIN SSS/GSISCIVIL STATUS
MOBILE NUMBER TELEPHONE NUMBER EMAIL ADDRESS
EMPLOYER/BUSINESS MOBILE NUMBER
EMPLOYER/BUSINESS ADDRESS
EMPLOYER/BUSINESS TELEPHONE NUMBER EMPLOYER/BUSINESS EMAIL ADDRESS
PERMANENT ADDRESS
(number, street, municipality/city, province)
PRESENT ADDRESS
(number, street, municipality/city, province)
COUNTRY ZIP CODE COUNTRY ZIP CODE
Single Married Others
Tick if same as
present address
LO/RFI/JEC/032718
PAGE 2
RFI
