Application Date/ Tarikh Permohonan: - - (Day-Month-Year/ Hari-Bulan-Tahun)

Policy Number/ Nombor-nombor Polisi: 1) 3)

2) 4)

Assureds Name/ Nama Pemunya Polisi:

Note: Please select the category & write clearly in CAPITAL letters./ Nota: Sila pilih kategori & tulis dengan jelas dalam huruf BESAR.
ADDRESS DETAILS/ BUTIR-BUTIRAN ALAMAT - Please tick () if there is change in address./ Sila tandakan () jikalau terdapat penukaran alamat.

Correspondence Address/ Alamat Surat-Menyurat Residential Address/ Alamat Tetap


Address Line 1/ Alamat 1
Address Line 2/ Alamat 2
Postcode/ Poskod City/ Bandar:
State/ Negeri
Country/ Negara

Note : Please specify the reason for the change of local to post box or foreign correspondence address.
Nota : Sila nyatakan sebab untuk penukaran alamat tempatan kepada peti surat atau alamat luar Negara. _________________________________



Business Address/ Alamat Perniagaan/ Syarikat Business Registered Address/ Alamat Pendaftaran Perniagaan/ Syarikat

Address Line 1/ Alamat 1
Address Line 2/ Alamat 2
Postcode/ Poskod City/ Bandar:
State/ Negeri
Country/ Negara

Please tick () if there is change in business/ company nature. Sila tandakan () jikalau terdapat penukaran dalam jenis perniagan/ syarikat.

Financial institution
1
/Institusi kewangan
1


Professionally Managed
Trust
2
/Profesional
Pengurusan Amanah
2
Others/Lain-lain

1
Financial institution refers to any organization that holds a banking, securities, and/or life insurance license. Examples of financial institutions include banks, life
insurers, custodians, asset managers, investment funds.
Institusi kewangan merujuk kepada mana-mana organisasi yang memegang perbankan, sekuriti, dan/atau lesen insuran hayat. Contohnya, institusi kewangan termasuk bank,
syarikat insurans hayat, kustodian, pengurus aset, dana pelaburan.
2
Professionally Managed Trust refers to any legal arrangement or structure that holds and controls asset(s) for the benefit of others (i.e. an individual or company
that is not the trust or trustee).
Profesional Pengurusan Amanah merujuk kepada mana-mana pengaturan undang-undang atau struktur yang memegang dan mengawal aset untuk manfaat pihak-pihak lain (iaitu
seseorang individu atau syarikat yang tidak diamanahkan atau pemegang amanah).
CONTACT DETAILS/ BUTIR-BUTIR PERHUBUNGAN

Mobile Telephone No./ No.Telefon Bimbit: - Country/ Negara:
Residence Telephone No./ No. Telefon Kediaman: - Country/ Negara:
Business Telephone No./ No. Telefon Perniagaan: - Country/ Negara:
Email/ Emel:

PREFERRED MODE OF CONTACT/ KAEDAH KOMUNIKASI YANG DIINGINI - Please tick () ONE only./ Sila tandakan SATU sahaja.


Mobile Telephone No./
No. Telefon Bimbit

Residence Telephone No./
No. Telefon Kediaman

Business Telephone No./
No. Telefon Perniagaan


STATEMENT OF DECLARATION/ KENYATAAN PENGAKUAN
I DECLARE that the above update is TRUE./ Saya MENGESAHKAN bahawa perubahan diatas adalah BENAR.


Name/ Nama:






NRIC No./ No. Kad Pengenalan:


Signature of Assured/ Policy Owner/Tandatangan Pemunya Polisi



CHANGE OF ADDRESS AND CONTACT DETAILS FORM
BORANG PENUKARAN ALAMAT DAN BUTIR-BUTIR PERHUBUNGAN
Prudential Assurance Malaysia Berhad (107655-U)
Level 17, Menara Prudential, No. 10, Jalan Sultan Ismail, 50250 Kuala Lumpur.
P.O. Box 10025, 50700 Kuala Lumpur.
Customer Service Tel: 603-2116 0228, Fax: 603-2032 3939 Email: customer.mys@prudential.com.my
Version/Versi Oct 2013
Form ID 11201029