Notice of Cancellation

To: Customer Care Department

Chubb Insurance Malaysia Berhad
Wisma Chubb
38 Jalan Sultan Ismail
50250 Kuala Lumpur

Subject: Policy Cancellation

Policyholder’s Name:

NRIC No.:

Policy No.(s)

I/We hereby give you, Chubb Insurance Malaysia Berhad (“Chubb”) one (1) month’s written notice to cancel the abovementioned Policy(ies),
subject always to the terms and conditions of the Policy(ies).

Reason for cancellation:

Thank you.

Yours faithfully,

Policyholder’s Signature

Name:

NRIC No.:

Mobile No.:

Email:

Date:

Note: Kindly email the completed Notice of Cancellation to CustomerCare.MY@chubb.com. Alternatively, you may fax it to 03-20583088.

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Published 01/21/V1