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 RELATIONSHIP DATE OF BIRTH

GENDER COMPLETE ADDRESS
(Surname, Given Name, MI) to the Insured (mm/dd/yyyy)

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 undersigned, 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 receipt of such request.

“If any Beneficiary shall 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. “

Executed at ____________________________ on ______ day of ______________________.

Witnessed by:

Name of AAO/Designation

Agency

Right Thumbmark
Signature of Insured (if unable to affix signature) Signature