CRISIS Cancellation Form AFRICAN UNITY

SHIELD OR UFE
Family Shield
info@crisisshield.co.za
Email:

Surely Underwit1ng Agents (Pty) Ltd (2016/395443/07) is an authorised FinancialServices Provider FSP 47867
Underwr itten by African Unitv Life Ltd (2003/016412/O6). A Licensed Long-Term Insurer and an authorised Financial Services Provider FSP 8447

DETAILS OFTHE MAIN MEMBER OR PRINCIPAL INSURED

Name |KsTLOANO Surname MASILo
1D Number 2 3 1 Policy number
ID Type RSA Y% No Other, specity
Cell Number O63 725 6209 W H

Email Address Cmastlo 94 qnqil-co

Pestal Address Taa Boluni Roud MoETSANE SowETO Postal Code 1868

Employer SANOF Department DO Facility/Unit Name 3 alitar hospital

Occupation MGDS Employee/Force No oo132419 MG X Temporary Permanent

POLICY CANCELLATION
I would like to cancel my cover because of:
Please tick
Price Affordability X Bad service Other (specify)
Please explain reasons for cancellation:
MSAs Co tract and 5 Soon endng So cannot
ffor
to

TERMS AND CONDITIONS/DECLARATION BY THE MAIN MEMBER

1 This application form serves as an addendum to my policy document. Full terms and conditions are available from the Underwriter on request.
2 Ideclare that the information given on this application form is true and accurate and Iunderstand that any misrepresentation or non-disclosure or false information
can lead to the immediate cancellation of this policy and its benefits, in which case allpremiums paid will be forfeited.
3. laccept that with this authorisation I am reducing my right to privacy. However, to assess the insurance risks, and to consider claims for benefitsl authorise African
Unity Insurance toobtain from any person whom Ihereby permit and request to give any information which Africarn Unity Life Ltd may need and to share with any
other insured that information, and any information in this application or any related sources at any time (even after my death).
4. All cancelations require the ID document of the Main Member to prove the authenticity of the cancellation.

PRINCIPAL INSURED ACCEPTANCE AND SIGNATURE

Member's Signature Date