Africa Merchant Assurance Co. Ltd.

Transnational Plaza, 2nd Floor, Mama Ngina Street

P.O. Box 61599 Nairobi – Kenya,
Tel: (Pilot line) 312121, Fax: 340022
E-mail: marketing@amaco.co.ke

SUSPENSION REQUEST FORM

Insured Name______________________________________________

Reg No. Cert No:

(KINDLY ATTACH ORIGINAL AND DUPLICATE OF CERTIFICATE)

Policy No. ___________________________

Period of cover: From_________________To ________________

Annual Premium: ______________________ Premium Paid ________

Policy suspension date: _________________

Reason for suspension:

Name of person completing this form:__________________________________

National ID No.____________________ Mobile Phone NO.__________________

Date: ___________________________ Signature __________________