CLAIMS FORM

NAME OF BENEFICIARY:

Policy Number:

Product

Title (Mr/Mrs/Ms/Others):

Phone Number

Surname:

First Name:

Middle Name:

Email:

WHAT IS THE NATURE OF YOUR REQUEST? TICK AS APPROPRIATE:

Policy Loan (for Entrepreneurial Plan only):

Part Withdrawal (60% of Total Contribution):

Policy Maturity:

Disablement:

Personal Accident:

Critical Illness:

Death:

Others:

DECLARATION:

I (We) - the undersigned, is/are the legal owner(s) of this policy and the information/intent provided here is correct.

Name:

Date:

Signed:

Signed (Only for the Joint Life and Savings Policy):