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THE FAMILY INDEMNITY PLAN

CHANGE OF PLAN

This Change of Plan shall be effective on the first day of the month following the date the insured delivers this form to and is received by you organisation.

Organisation: *


Certicate Number *

Membership Number *


Member Full Name: *


Current Plan:

Current Benefit Amount:


New Plan :

New Benefit Amount:

Effective date of Change:


New Premium Due:

Date Paid:


I understand that there will be a six (6) months waiting period for the higher benefit under this change of plan. I also understand that if a claim is incurred during the six months waiting period, the claim benefit be based on the original plan (except in the case of an accidental death).

I further understand that starting with the Effective Date of Change, the premium I will pay will be greater due to the increase in coverage under the new plan.


(Signature of Member)

(Signature of Authorized Organisation Officer)

(Date)