Gulf Insurance Ltd.

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Withdrawal

Withdrawal

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Policy No*
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
Was an Indemnity Form or Lost Policy Declaration Form completed ?*
Please Do Not Continue Request UNLESS one of the forms are completed above.
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
Was a Minor/Child Letter Completed?*
- Yes
- No
Please Do Not Continue Request UNLESS a Minor Letter was completed.
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 on Account*
Please enter a number greater than or equal to 0.
Branch of Request/CSR*
Preferred Branch*
Preferred Branch1
Select withdrawal amount*
- Maximum
- Specific Amount
Type-in of numerical value*
Please enter a number greater than or equal to 2000.
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
Beneficiary Signature
Beneficiary must sign within 5 working days, otherwise request will be cancelled.
Date
Date Format: MM slash DD slash YYYY
Comments
Additional Comments
Declaration*
- I hereby agree that any withdrawal from this policy may have an adverse effect on the Policy's current and future accumulated net fund value.
- I hereby agree that as my Cost of Insurance increases annually, the monthly premium currently being paid may be insufficient to cover the increased contractual monthly cost of this policy and may result in a negative net fund value, at which time the policy will automatically lapse.
Declaration
- I confirm that I am the owner and payor of the above-mentioned policy, and would like to request a withdrawal from the policy, for the sole benefit of my named beneficiary.