Increase_to__7500 by niusheng11

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									       FUNERAL PLAN                              FUNERAL PLAN                              FUNERAL PLAN

  REQUEST TO INCREASE COVER                 REQUEST TO INCREASE COVER                 REQUEST TO INCREASE COVER
     FROM $5,000 TO $7,500                     FROM $5,000 TO $7,500                     FROM $5,000 TO $7,500


Name of insured:                          Name of insured:                          Name of insured:

………………………………………………                        ………………………………………………                        ………………………………………………

Member number:………………………….                 Member number:………………………….                 Member number:………………………….

Date of increase: …………………………              Date of increase: …………………………              Date of increase: …………………………


      I understand that the increased          I understand that the increased          I understand that the increased
       cover applies immediately for             cover applies immediately for             cover applies immediately for
       death from accidental causes              death from accidental causes              death from accidental causes

      I understand that the increased          I understand that the increased          I understand that the increased
       cover for death by other than             cover for death by other than             cover for death by other than
       accidental causes (illness,               accidental causes (illness,               accidental causes (illness,
       suicide) applies 12 months after          suicide) applies 12 months after          suicide) applies 12 months after
       the date of increase shown above          the date of increase shown above          the date of increase shown above


Signature of insured:                     Signature of insured:                     Signature of insured:


..……………………………………………..                     ..……………………………………………..                     ..……………………………………………..

             Date ……./……../………..                       Date ……./……../………..                       Date ……./……../………..

								
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