Amendment Form

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REQUEST FOR AMENDMENT/CORRECTION OF ANGELICA PLAN AGREEMENT

PLANHOLDER_____________________________________LPNumber:_____________________________
ADDRESS ____________________________________________________________________________________
AMENDMENT REQUESTED:
1. Check the necessary box and give details.
2. Submit present Angelica Plan Policy or Affidavit of Loss.
FROM TO
[ ] a. Planholder :________________________ ________________________*attached
application of the new planholder.
[ ] b. Birthdate :________________________ ________________________
[ ] c. Address :________________________ ________________________
[ ] d. Beneficiary/age :________________________ ________________________
:________________________ ________________________
:________________________ ________________________
[ ] e. Plan type :________________________ ________________________
[ ] f. Payment Mode :________________________ ________________________
[ ] g. Contract Price :________________________ ________________________
[ ] h. Installment Amount: ______________________ ________________________
i.________________________ :________________________ ________________________
(others please specify)
It is hereby agreed that upon the surrender of the present CCLPI Agreement for a re-issue, the
undersigned consents to its cancellation and releases/clears CCLPI from all claims/demands and
liabilities.
I hereby certify that all the above details are true and correct and any erroneous or untruthful
statement shall not subject CCLPI to any liability whatsoever for any consequence arising therefrom.

Signed this ______day of ____________2023 at ________________________________________

______________________________________________
Printed Name & Signature of Planholder
Verified by:_________________________________

Agent’s Name:__________________________
Code :__________________________

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