DISCHARGE VOUCHER FORM

Policy Number:

Claim Number:

Issue Date:

Payee:

Class of claim:
(Maturity, Surrender, Death claim, ………. etc)

Amount Due:

Amount due to the company:

Net Amount Payable:

Declaration: I the undersigned claiming as the Assured/Named Beneficiary hereby authorize and request Heirs Life Assurance
Limited to pay the net amount above being

Amount

by cheque/transfer payable to me in full satisfaction and discharge of all claims in respect of the above life policy. I do further solemnly and sincerely declare that I am the legal holder of this Policy/Beneficiary and that my Estate has not been sequestrated, assigned or pledged this policy either by ante-nuptial contract or otherwise to anyone, is not subject to any prior or preferment claim and has not, except in favour of the Company been encumbered in any manner whatsoever.

BANK ACCOUNT DETAILS:

Type of Account:

Bank Name

Account:

BVN

Account Name:

Title:

Surname:

First Name

Middle Name

Signature:

Date:

Witness Details:

Account Name

Title:

Surname:

First Name

Middle Name

Occupation:

Tel

Contact Address

Signature:

Date:

OTHER INSTRUCTIONS:

Please choose the option preferred by ticking in the box against your desired instruction.

I wish to receive the benefit as a lump sum now.

I wish to use my maturity proceeds with Heirs Life as collateral for a short term loan of N………………... for a period
of ………………….. Months.

Loan Amount:

Month:

I wish to further reinvest my maturity proceeds with Heirs Life for a period of …………months where my funds will receive
attractive interest rates and accumulate wealth.

Month:

I wish to receive………% of my maturity proceeds and reinvest ……..% balance as a roll over reinvestment for a
duration of..........months/year.

balance:

months/year: