Great REPLY SLIP Eastern KERATAN KEBENARAN Life is Great Insurance Certificate No. ! No. Sil nsurans: 1/We, Saya/Kam, Name of Assured Member / ‘Nama Anil yang Diasuranskan NRICNo/NOKP Name of Joint Life Assured Member / Nema Ahli yang Diasuranskan Hayat Berpasangan NRIC No / No KP | Pease ol) wtichverapleatie Sand) manomana a Baran Hereby agree to continue the insurance coverage under the above policy. dengan ini bersetuiu untuk meneruskan perlindungan insurans di bavrah polisi yang dinyatakan. Hereby agree to surrender the above policy. dengan ini bersetuju untuk menyerahkan semula polisi yang dinyatakan, Ie give Great Eastern Life Assurance (Malaysia) Berhad (herein below referred to as the ‘Company’) full and complete discharge of its liabilities under this Policy and any future claims which could be made against it by Virtue of this Policy by me/us or by anyone whomsoever. We understand that the actual net Surrender value shall only be determined as at the date the Company receives this fully completed Reply SI ‘Saya/Korn dongen ii mombor! Great Eastom Life Assurance (Maleysio) Borhod (a sii cnyuk sobaga‘Syarkat) Kebonaran ponuh dan Tengkap bobas dari segala anggungjavabrya di bawah Pols ni dan dr apa-epe tuntuten pada masa depan yang boleh dbvat ci bawah Polls leh sayankami atau sesgpa sekelpun. Saya/Kami memanany banawa nil soranan bersin sebenar akan hanya dentukan pada {ankh Syankt menerima Keraten Kebenaran yang slop isi Signature of Assured Member Signature of Joint Life Assured Member Signature of Witness. TTandatangan Ahi yang Diasuranskan Tandatangan Ani yang Diasuranskan TTandatangan Soksi Borpasangan Date: Date: Name: NRIC: Address: TelNo: lnase note: ‘Signalure(s) of Legal Owner(s) on this form should be similar to that in our records. Tandatangan pemik sah ol atas Goran i harusian ‘sama dengan rohed yang dsinpen oleh Kam Each signature must be wlinessed by a disinterested party. Sotopfandtangan mos elsatsitan ole phok yang tak berkenaan Ifyou opt to surrender the policy, please return this sip along wah the Original Policy and Assignment Deed (f any). Sekranya anda ‘namin untuk renyerah pols sia puiangkan kertan by bersortakan Pots Asal dan Bovang Soran Hak ka 2). ifthe Orginal Policy andlor Aseigrmert Deod islare lest, we requir a statutory declaration and an indemnity. The declaration and indemnity forms are obtainable from Customer Service Counter, Solvanya Pols! Asal éanialau Borang Serah Hak hilag, kam memerukan ‘luen berkanun dan surat inom yang Bolen etapa KaunterPeriionelan Petanagan (mentee OR Bancazsrance Binet Level 6 Menara Great tr 33 aan Apa S045 Kal Lumpur “e340 88 (09) 48130508 boncadmioggrestensemitecom wo gtaenitenecom ec Latahenv01052012