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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 or surrender letter?
- Yes
- No
Please select reason for Surrender
Other
Was 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
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.
Date
Date Format: MM slash DD slash YYYY