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STANDARD ALLIANCE LIFE ASSURANCE - CLAIM ADVICE FORM


Firstname:
Lastname:
Type Of Policy:
Policy Number:
Policy Duration:
Frequency Of Payment:
Mode Of Payment:
Commencement Date:
Total Contribution:
OPTIONS OF CLAIM(Please select as appropriate):
Issue me an Open Cheque Re-Invest my Benefit Pay accumulated interest and re-invest my principal
I hereby authorized STANDARD ALLIANCE LIFE ASSURANCE LTD, to carry out my instruction as indicated and endorsed my policy appropriately.

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