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TOKIOMARINE

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TOK|O MARTNE L|FE TNSURANCE MALAYSTA BHD. (457556-X)


LCS CANCELLATION FORM

Date:

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Tokio Marine Life lnsurance Malaysia Bhd Menara Tokio Marine Life Level 7, No.189, Jalan Tun Razak 50400 Kuala Lumpur Attn: Group Operation Department

Fax: 03-2161 6068

Dear Sir/Madam,

Surrender of LCS (LIFE CREDIT SHIELD) Certlficate Number:

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Reference is made to above subject.

1)

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[*ur (ia,J rJd

hereby declare that I wish to cancel the

aborementionedpolicywitheffectivetrom

l.Q I d? r 3$f3-(DD/MM/YY-asattoday'sdate).

2) contacrNo., Or)

- 85\1843
b

3) RHB credit card number(s):

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Thank you.

Yours sincercly,

Name as in NRIC NRIC No.

: Lfinl
=

6tlJ

"|a

11Ot-18-R-m,r>

Pago 1 of

Grcund Floor, M6nare Tokio Mafino Lits, 189, Jalan Tun Reeak, 50400 Kuala Lumpur. Tel: 60$2059 6188. Fax 00$2161 068. Webolte: wv!,ur.lokiornarindib.com

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