Corona on Life Assurance

INDIVIDUAL LIFE PAYOUT/CLAIMS REQUEST FORM

Please complete in capital le ers
Policy Number:

Name of Assured:

Type of payout: Par al liquida on

Termina on
Death
Disability
Medical Expense
Maturity
Reason for termina on/surrender

(Please Ignore If Maturity Payout)

Amount requested: N
(If Par al Liquida on)
Balance in the account: N

Assured’s Bank Details:

Bank Name Account Number Account Name

Telephone:

Email:

Direct Debit Mandate

Deac vate my Direct Debit Yes No

Please note that by signing this form, the policy document issued to you at the incep on of the policy
becomes invalid henceforth (Except for Par al Liquida on and Medical expense Payout)

Policyholder’s Signature Date

Thank you for choosing Corona on Life Assurance Ltd