HLA POLICY SURRENDER/CANCELLATION FORM

Policy Number:

Title (Mr/Mrs/Ms/Others):

Surname:

First Name:

Middle Name:

Phone Number:

Email Address:

Residential Address:

State:

Country:

Date of Birth:

Identification Number:

Type of Identification:

International Passport:

Drivers License:

National ID:

Voter's Card:

Other:

Gender:

Male:

Female:

Reason for Cancellation/Surrender:

CONDITIONS AND RESTRICTIONS

To be completed by the Insured. Please select request:

I want to Surrender:

Cancel the Policy:

I understand that by this 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.

Please note that the Surrender Administration Charge may apply to my investment/endowment policy (ies) if I wish to surrender.

DOCUMENT REQUIRED: A fully completed and signed Cancellation or Surrender form

PAYMENT DETAILS: kindly ensure that the account name is the same as the insured's name

Account into which proceeds should be paid (For Surrender request only)

Bank Name

Account No

Branch Name

Type of Account:

Savings

Current

Account Name:

Title (Mr/Mrs/Ms/Others)

Surname

First Name

Middle Name

I, the undersigned declare that:

1. I am the legal owner of the Policy

2. I confirm that the information on this form is true and correct.

Policy Holder Signature:

Date: