APPLICATION OF SURRENDER / CANCELLATION FOR NON INVESTMENT LINK PLANS

Important Note: It is not in your best interest to surrender /cancel the policy
Loan Account No :
Policy No : Date :
(If applicable)

a. For Credit Insurance (Reducing Term Assurance).

I / We hereby confirm that the Loan/Overdraft in respect of which the Policy is issued has been fully settled.
b. I / We hereby apply to surrender/cancel the Policy and discharge Etiqa Life Insurance Berhad of all liability (ties) upon termination of the Policy and
upon payment of the Surrender Value (if any).
For Smart Family Medic, EasyMedic and OneMedical Only.
I/We hereby understand and agree that should there be any request for cancellation of one or more policies of the family package during the free look
period, the entire family package shall be cancelled, If the policies are issued at the same issue date.
c. I / We certify 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 has been instituted by or against me/us.
d. I / We hereby agree that a photographic copy of the Surrender/Cancellation Application Form shall be as effective and valid as the Original.
e. I / We authorize Etiqa Life Insurance Berhad to effect the Surrender Value payment by crediting to Maybank saving/current account as specified below:

Account Holder Name: _______________________________________________

(Policy Owner/Assignee only)

Bank Name: __________________________________________________ Bank

Account No

Life Assured
Details 2nd Life Assured Assignee / Trustee
Policy Owner (If different from Policy (If applicable) Witness
(If any)
Owner)

Signature

Name
NRIC No
Tel No

New
Address

Note: Witness must be at least 18 years of old, sound mind and not a named nominees or spouse to the Policy Owner.
TO BE COMPLETED BY ETIQA OFFICER / BANK OFFICER / AUTHORIZED PERSONNEL ONLY

1) For Non Credit Insurance (Ordinary Life and Reducing Term Assurance)
I / We hereby confirmed that I / We have explained the benefit of the existing product, option available beside surrender/cancellation and the disadvantages
of surrender/cancellation of policy. The policy owner is determined to surrender/cancel the policy due to,

Financial Difficulty Loan has been fully settled

Insurance is no longer required Unsatisfied with service provided by Sales Person/Company/others
Personal Reason Replacing with new policy
Product is not suitable Loan not approved

2) For Credit Insurance (Reducing Term Assurance)

I / We hereby confirmed and validate that the Loan/Overdraft in respect of the policy has been fully settled and loan account is closed. With this
Confirmation, Etiqa Life Insurance Berhad will take this validation as good and will proceed with the application for Surrender / Cancellation.
Details Etiqa Officer / Bank Officer / Authorized Etiqa / Bank Branch Manager
Personnel Only

Signature & Branch Stamp

Name
PF No
Designation
Date
FOR OFFICE USE ONLY
CWC Policy Dispatch Effective Date Entry Date
Surrender Date PV No Approved by

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