TYPE REQUIREMENTS
DETAILS OF LIFE INSURED
BRANCH RECEIPT DETAILS
HEAD OFFICE RECEIPT
DETAILS
FOR OFFICIAL USE ONLY
DETAILS OF POLICYOWNER
UPDATING
REDATING
Reinstatement Form duly dated, signed by the Life Insured and the Policyowner, witnessed and signed by the Agent/Unit Manager (UM)/
Branch Manager (BM);
Underwriting routine requirements; and
Payment of reinstatement cost.
Twelve (12) post-dated checks (PDC), PDC certification and PDC Monthly Agreement form; or
Two (2) original copies of the Automatic Debit Arrangement Enrollment Form with proof of bank account; or
With changes in personal details of the Policyowner in the records of Pru Life UK?
Yes (Fill out the additional KYC details section) No
PREMIUM RESUMPTION
Credit Card Enrollment Form duly signed by the Policyowner and photocopy of the front portion of the credit card.
If reinstating under monthly mode of payment, the following are strictly required:
Tick if same as Life Insured
STATEMENT OF INSURABILITY
This section should be completed by the Life Insured. The Policyowner portion should be completed if the Policy/ies has/have an existing payor waiver/payor term rider.
Life Insured Policyowner
1. Are you in good health, free from all diseases, deformities and abnormalities?
If no, please provide details.
2. Since the issuance of the Policy/ies or the last reinstatement, have you:
a) Ever had any illness or recurrent illness, injury, medication, or disease?
Yes No Yes No
Yes No Yes No
Yes No
Yes
No
Yes No Yes No
c) Ever been confined or hospitalized in a clinic, institution, or other medical facility?
d) Ever changed your customary occupation, or country of residence? If yes, please indicate details.
e) Ever had any application for life, accident or health insurance, or reinstatement that was
declined, postponed, rated, or modified?
f) Experienced death among the immediate members of your family? If yes, please provide
details.
Yes No Yes No
Yes No Yes No
Yes No Yes No
3. For female clients, are you now pregnant? If yes, how many months?
Yes No
Yes No
b) Ever had any medical consultation, hospitalization, or surgical operation due to any condition,
or been prescribed for or attended by a physician or practitioner for any cause, or undergone any
diagnostic test/s? Please indicate results.
SURNAME
GIVEN NAME
MIDDLE NAME
OTHER LEGAL NAME/ALIAS
DATE OF BIRTH
(mm/dd/yyyy) NATIONALITY
MOBILE NUMBER TELEPHONE NUMBER
OCCUPATION
(State exact duties; if member of AFP/PNP, state rank)
NAME OF EMPLOYER/NAME OF BUSINESS
SURNAME
GIVEN NAME
MIDDLE NAME
OTHER LEGAL NAME/ALIAS
DATE OF BIRTH
(mm/dd/yyyy) NATIONALITY
MOBILE NUMBER TELEPHONE NUMBER
OCCUPATION
(State exact duties; if member of AFP/PNP, state rank)
NAME OF EMPLOYER/NAME OF BUSINESS
Details of “YES” answer
Details
LO/RFI/JEC/032718
PAGE 1
GROSS ANNUAL INCOME
(in PhP) GROSS ANNUAL INCOME (in PhP)
PRU LIFE INSURANCE CORPORATION OF U.K.
9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
1634 Taguig City, Philippines
Customer helpdesk: (632) 683 9000, (632) 884 8484, (632) 887 LIFE
within Metro Manila, 1 800 10 PRULINK for domestic toll-free
Email: contact.us@prulifeuk.com.ph Website: www. prulifeuk.com.ph
REMINDERS:
Please use CAPITAL LETTERS and black ink.
Tick the appropriate box to indicate your choice.
Please do not sign on a blank form.
POLICY NUMBERS
Reinstatement Form
Individual Policyowner
One form may be used for multiple policies if the Policyowner and Life Insured in all policies
are the same. Otherwise, the individual submission of Reinstatement Form for each policy
will be required.
RFI
RFI
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
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RFI
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