Part 1 : Change of Address / Telephone No.

Part 2 : Change of Signature

Part 3: Change of Personal Particulars

Part 4 : Change of Nationality / Date of Birth

Part 5 : Change of Payment Mode / Method

Payment mode

Payment method

Both Policyowner and Life Assured Policyowner Life Assured

The change of address is applied to the address type below

Both Mailing Address and Residential Address Office Address

Mailing Address Residential Address

Flat / Room Floor Block Name of Building / Estate

No. and Name of Street / Road

District *Hong Kong / Kowloon / New Territories / Others (Please specify )

City/Country/Postal Code for foreign address E-mail Address

Telephone No.

New Signature of Policyowner New Signature of Life Assured

*Policy Owner / Life Assured

Name in English

Name in Chinese HKID/Passport No.

Relationship to Life Assured

Note: Please provide supporting documents i.e. copy of HKID or Passport (if no HKID) or Deedpoll (if applicable).

Nationality Date of Birth

*Yearly / Half-Yearly / Quarterly / Monthly (Please submit DDA form and two months' premium. )

*Direct Billing Autopay via Bank Account (Please submit DDA form. / Autopay via Credit Card (Please submit

Credit Card DDA form. )

( )

(Residential ) (Office ) (Mobile/Pager ) (Fax )

/

Note: For changes in Part 1, the changes apply to relevant data of all the policies (if any) under the same client

:

If not choose who is the address for, we will apply the new address for the policyowner only.

/

: :

/ /

:

/

)

Note: Monthly Mode must be paid by Autopay.

(only) (only)

Sex

/

Note: Please provide supporting documents i.e. copy of HKID or Passport (if no HKID) or Deedpoll (if applicable). ( )

(Please submit this application form to the Company 5 working days before the Effective Date for processing. )

Effective Date (dd/mm/yy / / )

:

Part 6 : Autopay Suppress Request

Section A Change of Policy Details

PAIAPA/FR01B (02/08) paiapa0301

Note 1. Please use to fill the appropriate box.

2. Please complete in BLOCK LETTERS.

3. * Please delete whichever is not appropriate.

Dark Pen Correct form

*

The Prudential Assurance Co. Ltd.

25th Floor, One Exchange Square

Central, Hong Kong25

Requested Effective Date # :

D D M M Y Y Y Y

# Leave this blank unless you have specific request on theeffective date of change. The Company shall have theright to determine the effective date of change uponacceptance of the Application.

Policy Number

Name of Insurance Consultant

Mobile phone no.

Division & Insurance Consultant Code

Name of Policyowner Name of Life Assured

Application For Change In Policy

Section E Declaration

I/We, the Policyowner(s), hereby request that my/our policy(ies) be changed in accordance with the particulars set out in this application and I/We understand and agree that such changes orservices will not take effect unless (1) any required documents and payments are submitted in full and (2) the application is duly approved by the Company.

/ / / (1) (2)

I/We, hereby declare and agree that nothing material has been withheld and the information given herein is true and shall be the basis of the contract. Any personal information collected or held bythe Company (whether contained in this application or otherwise obtained) may be held, used, provided, disclosed and transferred by the Company to any insurance agents, relatedcompanies/organizations or any selected parties, as determined by the company (within or outside Hong Kong) including but not limited to reinsurance and claims investigation companies, industryassociations/federations, professional advisors and the courts for the purpose of processing this proposal and claims, providing subsequent services in relation to this proposal and other productsand services, direct marketing, data matching, processing of payment instructions; and fulfilling any obligations as required by law from time to time. I/We further understand that under the PersonalData (Privacy) Ordinance, I/We have the right to request access and correction of any personal information provided to the Company; and that all such requests should be in writing and addressedto the Company's Data Protection Officer at the Company's principle office in Hong Kong. I/We further understand that the Company shall have the right to charge me/us a reasonable fee for theprocessing of any of my/our personal data access and correction request.

Section B Change of Policy Benefits

Reduction of Sum Assured to

Deletion / Reduction of Benefit /

Benefit DescriptionDeletion Reduction

Section C Request to re-issue Medical Check-up Coupon

Section D Other Changes

Request to re-issue for * Medical / Female Medical Check-up Coupon * /

Reason for the request (Please provide supporting document ) :-

Please specify :-

Signed atDayPlace

on ofMonth Year

Signature of Policyowner

HKID / Passport No. of Witness (if no HKID)

/

Signature of Witness Name of Witness (in Block letters)

Signature of *Irrevocable Trustee/Assignee (if applicable)

/

Signature of Life Assured

(Two witnesses are required if signature chop is used to sign. )

paiapa0302