Add or Remove Assignee

Policy No. (If unknown please tick box on the side)
Salutation
First Name*
Middle Name
Last Name*
Contact No.
Email
Address 1
Address 2
Town/City*
Country*
Please select the change that you would like to make:
- Add Assignee
Institution Name (Choose from list below)
Other
Institution Address
Address 1
Address 2
Town/City*
Country*
- Remove Assignee
Institution Name (Choose from list below)
Other
Institution Address
Address 1
Address 2
Town/City*
Country*
Signature of Policyholder
- Type-in Signature
- Digital Signature
Signature*
Signature*
Date*
Date Format: MM slash DD slash YYYY
Declaration*
I hereby confirm that I have submitted the Assignment form/ Release of Assignment form