APPLICATION FOR POLICY SURRENDER AND RELEASE IL c \GI Life Insurance Limited Mezzanine Floor, Kassam Court, Suite No. 101-103, BC-9, Block 5 Clifton, Karachi-75600, Pakistan Policy No. Policy Owner's Name Telephone Number Best Time to Call Application is hereby made for surrender of my policy and the payment of surrender proceeds (less any indebtedness to the Company secured by the policy) in accordance with the surrender provision in the policy. | understand and agree that the policy will seize to be in force as of the date of this Application for Surrender and in case | decide to cancel this request and maintain the policy in force before receiving the surrender proceeds. | shall submit a separate application to reinstate the policy in accordance with the conditions determined by the Company at the date of the reinstatement application. Itis hereby understood and agree that payment of the surrender proceeds and my receiving them shall constitute full and final settlement of all claims under the policy. Executed at this day of of 20 Witness. Signature of Policy Owner Witness Signature of Irrevocable Beneficiary OR Assignee