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 Kong 25 Requested Effective Date # : DDMMY Y Y Y # Leave this blank unless you have specific request on the effective date of change. The Company shall have the right to determine the effective date of change upon acceptance 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