Plot 66458 Fairground Office Park

Private Bag 00296 Gaborone Botswana

T +267 3645100/3951791
F +267 3905884
www.botswanalife.co.bw

MMOLOKI CASHBACK FORM

Date:

Policy Owner:

Policy Number:

Contact No. (Cell) (W) (H)

Email address:

I, the undersigned ____________________________________ wish to be paid out the

cashback value of the above policy, less any arrears accumulated.

Payment Details: EFT Liferewards

Bank Name:

Branch Name:

Account Number/ Liferewards Card Number:

Liferewards card expiry date:

Client Signature: __________________

______________________________________________________________________________
For Official Use Only:

Client Omang No: Expiry Date:

Name of staff member receiving documents:

Signature of staff: ____________ Date:

______________________________________________________________________________