AIA Bhd.

(790895-D )
Menara AIA, 99 Jalan Ampang
50450 Kuala Lumpur
P.O. Box 10846
50927 Kuala Lumpur
Care Line : 1800 18 1464
T : 03-2056 1111
F : 03-2056 3891

AIA.COM.MY

Attention :

Dear Sir / Madam

MDTA / OLTA / HPDTA / BLDTA / BLOLTA *

LA Reference No. / Policy No.:
* Please delete whichever is not applicable

1. I have not received a copy of my Certificate of Insurance as at today

2 I have not received my refund cheque being cash value / excess premium *

3. I would like to request for a copy of my medical report (s)

4. I would like to appoint nominee in respect of the above-mentioned policy

Name : _______________________________________ NRIC No : ________________________________

Relationship : __________________________________

5. I would like to change my correspondence address ( please fill in the space below )

6. I would like to cancel my MDTA / OLTA / HPDTA / BLDTA / BLOLTA *

( Bank chop, signature and staff name are required )

7. I would like to backdate the effective date of my Policy ____________________ ( dd/mm/yyyy )

( Bank chop, signature and staff name are required )

8. I have settled my loan with the Bank with effect from ______________________ ( dd/mmyyyy )

(a) Please proceed to cancel and to refund me with the Cash Surrender value ( if any ) , OR
(b) I wish to continue my policy and to nominate below as my nominee :-

Name : ______________________________________ NRIC No.: ______________________

Relationship : _________________________________

9. Others ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Bank
___________________________ Chop _________________________
Signature of Insured Authorised Signature
Name of Insured : Name of Bank Staff’s :
NRIC No.: Date :
Date :

Req.Form/V1.0/June’13