POLICYHOLDER

Policy Number: (*)

Title: (*)MrMrsMsOthers

Surname: (*)

First Name: (*)

Middle Name:

Date of Birth: (*)

Gender: (*)MaleFemale

Type of Identification: (*)International PassportDrivers LicenseNational ID CardVoters CardOthers

Identification Number: (*)

Enter BVN: (*)

Residential Address: (*)

State: (*)

Country: (*)

NATURE OF REQUEST - TICK AS APPROPRIATE

Part WithdrawalPolicy Cancellation/SurrenderReceive SMS NotificationsReceive Email NotificationsChange of Relationship Manager

Contact Details ChangeLoss Of Policy DocumentsPolicy Statement ReconciliationChange of AddressPolicy Renewal Request

Merger of PoliciesChange of BeneficiariesPolicy ChangePremium IncreasePremium Reduction

Other Requests:

Amount (#): (*)

Request Details: (*)

PREMIUM PAID, CONDITIONS AND RESTRICTIONS: (For Policy Cancellation/Surrender Requests)

Premium Paid: (*)

I understand that by submitting this request, my insurance policy with your company is terminated. I further understand that if I choose to cancel my Risk policy(ies), no refund will be made to me.

For investment/endowment Policy(s), Please note that Surrender Administration Charge may apply if you wish to surrender.

DECLARATION BY POLICYHOLDER

I, the undersigned declare that i am the owner of the policy and confirm that the information on the form is true and correct.

I, hereby consent to the collection, processing, and the transfer of my personal data to Third Parties (within or outside Nigeria). I affirm that I have read and taken cognizance of my rights under the relevant Data protection Laws and other terms detailed in the Data protection and Privacy of Heirs Life Assurance as found on Heirslifeassurance.com

Signature:

Date: