Form Pos 12 – Fill Out and Use This PDF

P.O. Box 4763

Syracuse, New York 13221-4763

Phone: (800) 959-3894

Fax: (315) 477-2828

USFLI-POS@AXA-Equitable.com

REQUESTFORPOLICYCHANGE

POLICYNUMBER:	AGENT:
POLICYOWNER:	INSURED:
POLICYOWNERADDRESS:	HEIGHT:	WEIGHT:	DOB:

SOCIALSECURITYNO:

HOMEPHONE:

WORKPHONE:

SELECTTHE DESIRED POLICYCHANGE TRANSACTION BELOW:

In order to prevent any delay in processing, please complete all required forms in their entirety,

including all doctor(s) information, complete address(es) and phone number(s).

Reinstatement forms can be found at www.usfli.com/policy owner service forms/reinstatement forms.

1.

Change policy stated amount from

to

.

(A completed reinstatement form is required for increase requests.)

2.

Add Rider/Benefit:

Child

Additonal Insured Person

Waiver

Accidental Death

(A completed reinstatement form is required for additions of any riders or waiver benefits.)

3.

Cancel Rider/Benefit:

Child

Additonal Insured Person

Waiver

Accidental Death

4.

Remove or reduce policy rating.

(A completed reinstatement form is required for rate or smoker class changes. For smoker

class changes, please include a completed tobacco questionnaire that is available on our

website-www.usfli.com/forms&software/questionnaires.)

5.

Change Death Benefit Option to:

Option A

Option B

6. Term Re-Entry. (A completed reinstatement form is required for Term Re-Entry requests.)

*COMMUNITYPROPERTYSTATES REQUIRE SIGNATURES OFBOTH SPOUSES*

NOTICE-Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. The above statements are complete and true to the best of my/our knowledge and belief.

Dated		at
			City	State
	Signature of Insured		Signature of Owner if other than Insured