REQUEST FOR AMENDMENT

Proposal No. New NRIC No.

- -
Policy No. Old NRIC/BC/Passport No.

Name of Life to be Assured:

Name of Proposer (if other than Life to be Assured):

Please fill in/tick box where appropriate.

APPLICATION CHANGES
Mode of Payment Yearly Half-Yearly Quarterly Monthly
(Note: Monthly mode is only applicable for payment method GIRO, Credit Card or Banker's Order.)

Method of Payment Cash Cheque GIRO Credit Card Banker's Order

(Note: For GIRO/Credit Card, please complete the GIRO/Easi-Pay Application Form.)

Basic plan to Plan Code

Premium to
RM
(Note: Change in premium will auto change the premium waiver rider sum assured (if applicable).)

Reduce Sum Assured

Plan Code Sum Assured
Basic Plan to
Plan Code Sum Assured
Rider to

Backdate commencement date to

/ / Cancellation of backdating

Change of Address Mailing Address Residential Address

Others

I hereby give my consent to the company for the amendment(s) requested. I certify that there has been no change in my condition of health and that I
have receive no medical attention, consultation or examination whatsoever, since the date of completion of the said application for life assurance. I
also certify that all my answers written in the said application for life assurance are still true.

I agree that the above statement shall form part of my application for life assurance.

Date
/ /
Day Month Year
FPMS

Signature of Life to be Assured Signature of Proposer (Owner)

(if other than Life to be Assured)

STATEMENT OF WITNESS
I hereby certify that the signature(s) in this form was/were made before me and that to my own personal knowledge it is the signature(s) of the
NBZ-FRQAM-V05-122015

Proposer/Life to be Assured under the Policy No./Proposal No. as mentioned above.

Signature of Witness (Agent)

Name :
NRIC No. :

Great Eastern Life Assurance (Malaysia) Berhad (93745-A)

Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur 4634096888
Telephone: +603 4259 8888 Facsimile: +603 4259 8000
E-mail: wecare-my@greateasternlife.com Website: greateasternlife.com