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CB-LEP/ELP-09252017 Designation of Additional/Change of Beneficiary/ies for LEP Policy Holders
GSIS form for designation of additional LEP and ELP
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DESIGNATION/CHANGE OF BENEFICIARY/IES FOR LIFE ENDOWMENT POLICY (LEP) AND
ENHANCED LIFE POLICY (ELP)
Please check the reason for designation or change of beneficiary/ies:
Without a legitimate spouse and legitimate, legitimated, adopted and declared illegitimate children.
Death of the designated beneficiary/ies.
Revocation of the legitimate spouse as beneficiary and the policy holder is childless.
I, ______________________, with Business Partner Number _____________________________ and insured
under Policy No. ______________ hereby request that the Beneficiary/ies named hereunder be acknowledged as
my Beneficiary/ies:
DESIGNATION OF BENEFICIARY/IES:
PRINTED NAME OF
BENEFICIARY/IES
(Surname, Given Name, MI)
RELATIONSHIP
to the insured
GENDER
DATE OF BIRTH
(mm/dd/yyyy)
COMPLETE ADDRESS
CHANGE OF BENEFICIARY/IES:
FORMER
BENEFICIARY/IES
NEW
BENEFICIARY/IES
(Surname, Given Name, MI)
(Surname, Given Name, MI)
RELATIONSHIP
to the insured
GENDER
DATE OF
BIRTH
(mm/dd/yyyy)
Executed at ____________________________ on ________ day of ________________.
_________________________________
Signature of Insured
COMPLETE ADDRESS
