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Surrender Policy

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*
Is the policy assigned?
- Yes
- No
Please select assignee from listing below
Other
Are you in possession of the policy contract?
- Yes
- No
Please select reason for Surrender
Other
Were any of the Beneficiaries added from inception of the policy?
- Yes
- No
Please select the relationship of the Beneficiaries
Is Beneficiary still a minor?
- Yes
- No
Please select your preferred method of payment
Please enter your account details
Name of Institution*
Account number*
Please enter a number greater than or equal to 0.
Branch of Account*
Branch of Request*
Preferred Branch*
Signature of Policyholder*
- Type-in Signature
- Digital Signature
Signature*
Signature*
Date
Date Format: MM slash DD slash YYYY
Signature of Beneficiary
- Type-in Signature
- Digital Signature
Signature*
Signature*
Declaration*
- I hereby agree that by surrendering my policy the cost of insurance may be subject to change should I decide to effect new coverage with the Company.
Declaration*
- I confirm that I am the owner and payor of the above-mentioned policy, and would like to request the Cash Surrender Value of the policy, for the sole benefit of my named beneficiary.
Date
Date Format: MM slash DD slash YYYY