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Form No 06232015-DACB
DESIGNATION OF ADDITIONAL/CHANGE OF BENEFICIARY OR BENEFICIARIES FOR LIFE ENDOWMENT POLICY (LEP) ONLY
□ Designation of Additional Beneficiary/ies
□ Change of Beneficiary/ies
It is hereby requested that the Beneficiary or Beneficiaries named hereunder be acknowledged as the Beneficiary
or
Beneficiaries
under
CM
Policy
No.___________________________
issued
by
the
GOVERNMENT SERVICE INSURANCE SYSTEM (GSIS), hereunder called the System, on the policy of Mr./Ms._____________________________________________ hereunder called the Insured with Business Partner (BP) Number _________________________:
PRINTED NAME (Surname, Given Name, MI)
RELATIONSHIP to the Insured
GENDER
DATE OF BIRTH (mm/dd/yyyy)
COMPLETE ADDRESS
If the said policy requires endorsement of change of Beneficiary, it is requested that the System: a) Waive all provisions of said Policy requiring endorsement of Beneficiary changes b) Accept this form when properly executed in duplicate and filed with the System as evidence of such waiver both by the System and the un dersigned, and c) Endorse said policy as follows: The member may change the designated beneficiary/ies or designate additional ones at any time while the insurance policy is in force. Such request should be made using the prescribed form and filed with the System. When so filed, it shall relate back to and take effect on the date the request was submitted to the agency without prejudice to the System on account of any payment it made before r eceipt of such request. “If any Beneficiary shall die die before the Insured, the interest of such Beneficiary shall vest in the Insured unless otherwise specifically provided.” “All provisions of this Policy heretofore in effect requiring endorsement of change of Beneficiary are hereby cancelled and annulled. annulled . “ Executed at ____________________________ on ______ day of ______________________. Witnessed by:
