Policy Change Application - ivari

LP386 6/17 Policy Change ApplicationAPPLICATION NO. Policy Change Application DETACH THIS PAGE AND AND DELIVER TO THE INSURED(S). Important instructions for the advisorUse this Application when applying for any changes to in force Life and Critical Illness policies such as: Addition of lives/coverage for Term and Critical Illness Protection insurance only Reinstatement Reduce or remove rating or Change in risk classification Changes to non-smoker Addition of Children s Insurance Rider Change of Death Benefit Option Increase in Face Amount* Conversion with underwriting* Change of Cost of Insurance* (COI) Substitution of life* Replacement of an existing ivari Policy ** Effective January 1, 2017 new tax legislation came into effect. This legislation will have an impact on policies issued before January 1, 2017 if certain changes are made to the Policy after December 31, 2016. Refer to for further details For quicker processing:1. The Notice of Disclosure (page i) must be given to the Insured(s).

Policy Change Application DETACH THIS PAGE AND AND DELIVER TO THE INSURED(S). APPLICATION NO. i Notice of Disclosures Thank you for continuing to do business with ivari. Before submitting this request to change your policy, ensure that you have carefully

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