For Office Use Only
C
A
W
REQUEST TO WITHDRAW CASH DIVIDEND AND CASH PAYMENT
FORM
Policy No.:
Plan Code :
Policy Owner Name
:
Policy Owner New IC No.
:
Name of Insured Person
:
Insured Person New IC No.
:
I/We would like to apply to withdraw net Cash Dividend & Cash Payment (Total declared Cash Dividend & Cash
Payment less total outstanding loan and interest, if any).
Please tick [√] if you wish to authorize Zurich Insurance Malaysia Berhad to execute your preferred choice:
Partial Withdrawal - Cash Dividend & Cash Payment Amount: RM
(Note: Minimum withdrawal amount is RM500.00)
To withdraw ALL the accumulated Cash Dividend & Cash Payment.
I/We understand and agree that the above withdrawal will reduce my/our policy values or death benefits. It is
also understood that the discontinuance of premium payment will cause the termination of my/our policy when
the policy values become nil (This is in accordance to the Automatic Non-Forfeiture Provisions as stated in the
policy document).
Declaration and Authorisation
A) I/We hereby give my/our unconditional and unequivocal consent to you and all your related companies to
process my/our personal data revealed hereto. You are at liberty to process the data and share the
information revealed thereto with any of your service providers and your other related companies provided
that the revelation of my/our personal data is strictly for the purposes in relation to the insurance which I/we
have applied hereto. The consent given hereto is in line with the requirement set forth in the Personal Data
Protection Act 2010.
B) I declare that at this time, I am not a citizen, resident or person subject to the taxation laws of any other
country except for the country or jurisdiction which I have declared save and except for the country which I
/we have declared hereto.
I hereby undertake to notify you in writing in the event that my/our status changes in the future, for any
reason, causing me to become subject to any taxation law or legislation of any other country.
I hereby grant you my full and unconditional authority to notify any relevant foreign tax authority to which you
consider that you or I become subject as a result of any future change to my taxation status without giving me
prior notice for such actions.
I hereby declare that I am not a United States Citizen or United States Resident for Tax Purpose.
For United States Citizen or United States Resident / Taxpayer, please tick the box.
I would like to receive the payment via the option below:Credit into my bank account: Bank: ……………………… Account No.: .………………………………………...
Notes:
i) Please complete Electronic Fund Transfer (EFT) Instruction Form.
ii) Please submit 1st page of your Personal Bank Passbook or Latest Statement of Accounts.
To receive notification via email. My email address: ………………………………………………………..
By post to my correspondence address: …….………...……………………………………………………………......
………………………………………………………………………………………………………………………………...
To be collected in person at a Zurich Insurance Malaysia branch: ………………………..………………..……..
Through the servicing Sales
Advisor.
2058/2/P/L/S/M
Name: …………………………………………………………
Code: ……...........
QF-LPS-022/BI-Rev4
Policy No.:
Please update your email address, contact no. and new correspondence address.
Policy No.:
My email address:
My Contact No.:Residence:
Office:
Handphone:
My current correspondence address:
Signed in the presence of
…………………………………………..
Signature of Witness*
Name
I/C No.
Date
Address
:
:
:
:
……………………………………………..…
Signature of Insured Person
(Note: Not applicable for Juvenile Insurance)
Name
:
Contact No. :
Date
:
……………………………………………..…
Signature of Policy Owner
Parents/Legal Guardian (if Juvenile Insurance)
Name
:
Contact No. :
Date
:
…………………………………………..……
Signature of Assignee / Trustee, if any
Name
:
Contact No. :
Date
:
* The witness must have attained the age of 18 years.
Zurich Insurance Malaysia Berhad (8029-A)
11th Floor, Menara Zurich, No. 12, Jalan Dewan Bahasa, 50460 Kuala Lumpur, Malaysia
Tel: 03-2146 8000 Fax: 03-2142 5863 Call Centre: 1-300-888-622