TOKIO MARINE LIFE INSURANCE MALAYSIA BHD. (457556-X)

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Ground Floor, Menara Tokio Marine Life, 189, Jalan Tun Razak, 50400 Kuala Lumpur. Tel: 603-2059 6188. Fax: 603-2161 6068. Website: www.tokiomarinelife.com.my

Date: _____ /_____ / _____ Tokio Marine Life Insurance Malaysia Bhd Menara Tokio Marine Life Level 7, No.189, Jalan Tun Razak 50400 Kuala Lumpur Attn: Banca Operations Department Fax: 03-2161 6068 Dear Sir/Madam, Surrender of LCS (LIFE CREDIT SHIELD)

Certificate Number:

Reference is made to above subject. 1) I, _____________________________________ hereby declare that I wish to cancel the

above mentioned policy with effective from _____ /_____ / _____ (DD/MM/YY- as at todays date). 2) Contact No.:______________________________ 3) RHB credit card number(s):

I. - - -

II. - - -

III. - - -

IV. - - -

V. - - - Thank you. Yours sincerely, ________________________________ Name as in NRIC : NRIC No. :

LCS CANCELLATION FORM

FORM