Form 16

Head Office, Dar-es-Salaam Place Cairo Road, P O Box 33384 Lusaka

Tel: 233940/1 Fax: 233936 E-mail: mlife@mlife.co.zm

INDIVIDUAL LIFE ADMINISTRATION DEPARTMENT

DECLARATION BY CLAIMANT AND DISCHARGE FORM

Policy Number: ……………….……………… Life Assured………………..……………...

I, the undersigned (Legal Policyholder) …………………………………of

address……………………………………………...………………………………………….

Telephone number (Office)………………………….. Mobile …………..…………………

declare that:

(1) I am the legal holder of the policy.

(2) My estate has not been declared bankrupt and is at present solvent and

(3) I have not ceded or transferred my rights in the policy to anyone except in
so far as it may be pledged to Madison Life Insurance Company Zambia
Limited in respect of any loan thereon.
I hereby apply for the partial redemption or complete redemptions/surrender or full
maturity (delete whichever is not applicable) of K………………………. on the above
mentioned policy and confirm that payment of such proceeds by Madison Life
Insurance Company Zambia Ltd shall represent the partial or final discharge of
Madison Life Insurance Company Zambia Limited’s liability under the said policy.

Signature of the Legal Policyholder:……….…………..…….Date:……….……..………..

Name of Payee:……………………………………………………..………………………...

Account Number:………………………………………..…………………………………….

Name of Bank:………………………...……………………………………………………….

Name of Branch:………………………….………. Sort Code ……………………..………

Name of Bank:………………………...……………………………………………………….

Name of Branch:………………………….………. Sort Code ……………………..………