Indemnity Form

IN THE MATTER OF POLICY NO: GEM/TD/T0 :

Issued by Assuria Life (T&T) Ltd ., formerly MEGA Insurance Company Limited, on the life of
Full Name
I
Salutation
First Name*
Middle Name
Last Name*
Contact No.
Email
Hidden
Address 1
Hidden
Address 2
Hidden
Town/City*
Hidden
Country*
Is the policy assigned?
- Yes
- No
Please select assignee from listing below
Other
Select withdrawal amount
- Maximum
- Specific Amount
Type-in of numerical value
Signature of Policyholder*
- Type-in Signature
- Digital Signature
Signature*
Signature*
Date
MM slash DD slash YYYY
Policy Owner Signature
- Type-in Signature
- Digital Signature
Signature*
Signature*
Date
MM slash DD slash YYYY
Declaration*
- I hereby agree that any withdrawal from this policy may have an adverse effect on the Policy's current and future accumulated net fund value.
- I hereby agree that as my Cost of Insurance increases annually, the monthly premium currently being paid may be insufficient to cover the increased contractual monthly cost of this policy and may result in a negative net fund value, at which time the policy will automatically lapse.
Declaration
- I confirm that I am the owner and payor of the above-mentioned policy, and would like to request a withdrawal from the policy, for the sole benefit of my named beneficiary.