This document is a request form from an individual to an insurance company to update their correspondence address. It contains the individual's name, new address, residence and office phone numbers, mobile number, policy number, application date, and a declaration signed by the individual stating that the address update information provided is true. The form also contains contact information for the insurance company.

1. Version 2, Sept 3, 2007
PLEASE WRITE CLEARLY IN BLOCK LETTERS
(dd/mm/yyyy)
New Correspondence Address:
Alamat Surat-menyurat Baru:
Postcode:
Residence phone: -
Office phone: -
Handphone: -
STATEMENT OF DECLARATION / KENYATAAN PENGAKUAN
I/We DECLARE that the above update is TRUE.
Signature of Assured / Tandatangan Pemunya Polisi
Request For Change of Address
Permintaan Untuk Menukar Alamat
Policy Number(s) /
Nombor Polisi-
polisi
Application Date /
Tarikh Permohonan
Form ID 11201029
Prudential Assurance Malaysia Berhad (107655-U)
Level 17, Menara Prudential, No. 10, Jalan Sultan Ismail, 50250 Kuala Lumpur.
P.O. Box 10025, 50700 Kuala Lumpur
Customer Service Hotline: 603-21160228 Fax: 603-20323939
E-mail: customer.mys@prudential.com.my
Assured’s Name /
Nama Pemunya Polisi