PRUSELECT VANTAGE PREMIER - NOTIFICATION OF DEATH FORM

This Death Notification is for the purpose of updating Policy Records should a Policyowner or Life Assured dies. Please note that
the Death Benefit on a PruSelect Vantage Premier Policy is payable only on the death of the last surviving life assured. There is no
death claim payable on this Notification.
For filing a death claim, please refer to the Death Claim Requirement in www.prudential.com.sg – Claims.
Mandatory Required documents for notification:
1. Death Notification Form for update of Life Assured / Policyowner’s record, or equivalent issued by official authorities
2. Certified True Copy of Death Certificate of deceased Life Assured or Policyowner
3. NRIC or Passport of the Informant
4. Certified True Copy of the Grant of Letter of Administration / Probate (applicable in the event of death of last surviving
Policyowner)

PARTICULARS OF DECEASED LIFE ASSURED / POLICYOWNER

1. Name of the Life Assured / Policyowner in full – now RUSMIN SENTOSA

deceased

2. NRIC No. / Passport No. of the deceased

24 11 1966
3. Date of death
DD MM YYYY

PARTICULARS OF THE INFORMANT

NRIC No. /
Full Name
CLAUDIA Passport No.

PESONA KARAWACI C2 no 17. JL RAYA LEGOK

Address KELAPA DUA, BOJONG NANGKA
TANGERANG, JAKARTA, INDONESIA
Relationship to CHILD
Contact No. +62-818881213 deceased

DECLARATION

I declare that all information given in this form is, to the best of my knowledge and belief, true and complete.

Signature of Informant Date

04/08/2021
If there is a change in Mailing / Residential address as a result of this event, please contact your Prudential Financial Consultant or
call our PruCustomer Line at 1800 333 0333 or visit our corporate website at www.prudential.com.sg for more details.

Prudential Assurance Company Singapore (Pte) Limited 30 Cecil Street #30-01 Prudential Tower Singapore 049712
Postal Address: Robinson Road P.O. Box 492 Singapore 900942
Telephone: 6535 8988 Fax: 6734 9555 Website: www.prudential.com.sg
Part of Prudential Corporation plc Reg. No 199002477Z

ID CMDTHCLM PSVP Death Notification Claim June 2013