Organisation: *

Certificate Number *

Membership Number *

Member Full Name: *

This Change of Insured shall be effective only when the insured delivers this form to the organization through which he/she holds his/her certificate and the organization file the changes of Insured form with CUNA Caribbean Insurance Society Limited. You must inform the organization within 30 days of any change. If you do not inform the organization of a change within 30 days, there will be a six month waiting period for benefits due to natural death (accidental death benefits will be paid). At no time may more than six persons be insured under one certificate.

Check the situation which applies:

Divorce of the insured - deleting the former spouse and adding another insured.
Child has reached age 1
Child has reached age 26
Re-marriage of insured - adding the new spouse
Death of an insured

Other, Explain:

Name of the person being deleted:

Name of the person being added:

Sex:       F M

Relationship to Member: *

Date of Birth: *

I understand that there will no longer be any coverage on the person deleted from the plan. The person being added will be the newly insured under the plan.

It is the sole responsibility of the Insured to ensure that eligible persons for whom applications are made are not insured persons who have existing coverage under The Family Indemnity Plan as no person may be insured through more than one Family Indemnity Plan Certificate in accordance with the Non-Duplication of Coverage clause contained in the Insured Family Indemnity Plan Certificate. If a person is named under more than one Family Indemnity Plan Certificate on the death of such a person the in surer shall only be liable to pay the claim made under the Family Indemnity Certificate that is fist in time.

(Signature of Member)

(Signature of Authorized Organisation Officer)