Change of Address Form PAMB

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