For Office Use Only

Request for Cash Surrender

Please tick (✔) where applicable to authorise Zurich Life Insurance Malaysia Berhad to execute as per your request.

Policy Number :

Policy Owner Name :

is hereby surrendered for its cash surrender value according to its terms, together with all dividend deposits or additions of any
nature, if any, and is handed to you herewith for cancellation. The liability of Zurich Life Insurance Malaysia Berhad upon or in
connection with said policy is as of this date fixed and limited to such cash surrender value, and credits, if any, and upon payment
thereof, the said Company shall be and is hereby completely discharged.

Each person executing this agreement certifies that this policy is not now assigned, except as indicated below by the signature of the
assignee/trustee(s), if any, and that no proceedings in bankruptcy have been instituted by or against him, her or them.

Reason for Surrender:

I would like to receive the payment via the option below:-

Credit into my bank account

1 Name of Bank

2 Bank Account No.

3 Account Type Saving Account Current Account

4 Account Holder Name

5 Account Holder I.C. No.

6 Account Holder I.C Type

New I.C No. Passport No. Army or Police No.
(Note : I.C No. MUST be the
SAME as per record in your Old I.C No. Company No.
bank account)

7 Bank Branch Address

8 E-mail Address Contact No :

Important Notes:

1. This facility is applicable to bank account maintained with a financial institution that are offering MEPS inter-Bank GIRO
(IBG) service only.

2. This facility allows payment into your own bank account only. Joint Account is not encouraged.

3. The Electronic Fund Transfer (EFT) transaction is subject to Zurich Life Insurance Malaysia Berhad Head Office’s
approval date.

4. A physical cheque will be issued to you if the bank fails to credit the payment due to reasons provided by the bank.

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 Request for Cash Surrender
Policy Number :

Cheque (Effective 1st January 2018, all payments amount of RM100,000 and below will be paid via EFT transaction only)

By post to my correspondence address: …….………………………………………………………………………................

To be collected in person at a Zurich Life Insurance Malaysia branch: ………………………..……….………..……….

Through the servicing Sales Advisor Name: ……………………………………………….......Code: .....…………………

Declaration and Authorisation

Please tick (✔) the appropriate box:

I/We declare and agree on behalf of myself and any person or persons, firm or corporation, who may have or claims any interest in
the above stated Policy the following:

Policy Owner Assignee

Individual:
Yes No Yes No
i) Are you a Malaysian Resident for Tax Purpose?
ii) Are you a United States Citizen or United States Resident /
Taxpayer?
iii) Are you a Resident for Tax Purpose / Taxpayer of any country
other than Malaysia and United States?

Entity: Yes No Yes No

i) Is the Company / Entity incorporated outside Malaysia?

ii) Is the controlling person(s) a tax resident anywhere other than
Malaysia?

A) I/We declare that at this time, I/we am/are not a citizen, resident or person subject to the taxation laws of any other country except
for the country or jurisdiction which I/we have declared hereto. I/We hereby undertake to notify the Company in writing in the
event that my/our status changes in the future, for any reason, causing me/us to become subject to any taxation law or legislation
of any other country. I/We hereby grant the Company my/our full and unconditional authority to notify any relevant foreign tax
authority to which the Company consider that the Company or I/we become subject as a result of any future change to my/our
taxation status without giving me/our prior notice for such actions.

B) I/We hereby give my/our unconditional and unequivocal consent to the Company and all related companies of the Company to
process my/our personal data revealed hereto. The Company are at liberty to process the data and share the information
revealed thereto with any of the service providers and other related companies of the Company provided that the revelation of
my/our personal data is strictly for the purposes in relation to the insurance which I/we have applied hereto. The consent given
hereto is in line with the requirement set forth in the Personal Data Protection Act 2010.

Signature of Policy Owner/ Signature of Witness*

Parents / Legal Guardian (if Juvenile Insurance)

…………………………………………………………………………………………….. …………………………………………………………………………………………..
Name : Name :
I/C No. : I/C No. :
Contact No. : Contact No. :
Date : Date :
Foreign Residence Address of Policy Owner: Address of Witness:

*The witness must have attained the age of 18 years.

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 Request for Cash Surrender
Policy Number :

Signature of Insured Signature of Witness*

(Not applicable for Juvenile Insurance)

…………………………………………………………………………………………….. …………………………………………………………………………………………..
Name : Name :
I/C No. : I/C No. :
Contact No. : Contact No. :
Date : Date :
Foreign Residence Address of Insured: Address of Witness:

Signature of Assignee Signature of Witness*

…………………………………………………………………………………………….. …………………………………………………………………………………………..
Name : Name :
I/C No. : I/C No. :
Contact No. : Contact No. :
Date : Date :
Foreign Residence Address of Assignee: Address of Witness:

Signature of Trustee Signature of Witness*

…………………………………………………………………………………………….. …………………………………………………………………………………………..
Name : Name :
I/C No. : I/C No. :
Contact No. : Contact No. :
Date : Date :
Foreign Residence Address of Trustee: Address of Witness:

*The witness must have attained the age of 18 years.

Zurich Life Insurance Malaysia Berhad (8029-A)

Level 23A, Mercu 3, Jalan Bangsar, KL Eco City, 59200 Kuala Lumpur, Malaysia
Tel: 03-2109 6000 Fax: 03-2109 6888 Call Centre: 1-300-888-622
www.zurich.com.my

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