Prudential Surrender Form PDF Details

The Prudential surrender form is a document that policyholders can use to terminate their life insurance policy. The form must be completed and submitted to the insurance company in order to initiate the termination process. In this article, we will provide an overview of the Prudential surrender form and guide you through the steps involved in terminating your policy. We highly recommend that you speak with an insurance professional before making any decisions regarding your life insurance policy. Terminating a policy can have serious financial consequences, so it is important to understand all of your options before taking any action.

Listed below are some details about prudential surrender form. Before you decide to fill in the form, it is worth studying a little more about it.

QuestionAnswer
Form NamePrudential Surrender Form
Form Length3 pages
Fillable?Yes
Fillable fields26
Avg. time to fill out6 min 1 sec
Other namesprudential life insurance cash surrender form, surrender form prudential, prudential surrender request form, pruential life cash surrender form

Form Preview Example

APPLICATION FOR SURRENDER

PERMOHONAN UNTUK SERAHAN

Instruction: To be completed in DARK BLACK ink only and tick the boxes as appropriate.

Arahan: Sila isi dengan menggunakan dakwat HITAM GELAP sahaja dan tandakan dalam petak yang berkenaan.

Policy/Certificate Number/Nombor Polisi/Sijil

 

Assured/Master Policyholder’s Name/ NamaPemunya Polisi/Pemegang Polisi Induk

Application Date/Tarikh Permohonan

 

Life Assured/Insured Member’s Name/ Nama Hayat/Ahli Yang Diinsuranskan

Agent/Bank/Prudential Assurance Malaysia

 

Agent/Bank/Prudential Assurance Malaysia

Agent/Bank/Prudential Assurance Malaysia

Berhad Representative's Code/

 

Berhad Representative's Name/

Berhad Representative'sContactNumber/

Kod Ejen/WakilBank/Prudential Assurance

 

Nama Ejen/WakilBank/Prudential Assurance

Nombor TelefonEjen/Wakil Bank/ Prudential

Malaysia Berhad

 

Malaysia Berhad

Assurance Malaysia Berhad

 

 

 

 

 

PART 1: TYPE OF SERVICE REQUEST / BAHAGIAN 1: JENIS PERMOHONAN PERKHIDMATAN

I/We, the Assured/Assignee/Insured Member of the above mentioned Policy/Insurance Certificate, authorize Prudential Assurance Malaysia Berhad (“PAMB”) to surrender the Policy/Insurance Certificate and request PAMB to pay the Surrender Value in full discharge of the liability of PAMB under the said Policy/Insurance Certificate. I/We acknowledge that I/we have received information in items 1 to 2 of the following: (Please tick (√) where applicable.)/ Saya/Kami, Pemunya Polisi/Penerima Hak/Ahli Yang Diinsuranskan bagi Polisi/Sijil Insurans yang tersebut, membenarkan Prudential Assurance Malaysia Berhad (“PAMB”) menyerahkan Polisi/Sijil Insurans dan meminta PAMB untuk membayar Nilai Serahan dengan pelepasan dari liabiliti sepenuhnya bagi PAMB di bawah Polisi/Sijil Insurans ini. Saya / Kami mengakui bahawa saya / kami telah menerima maklumat dalam perkara 1 hingga 2 daripada yang berikut: (Sila tandakan (√) dalam kotak yang berkenaan.)

Investment- Linked Plan/ Pelan Berkaitan Pelaburan [08]

Traditional Plan/ Pelan Tradisional [01]

Universal Life Plan/ Insurans Hayat Universal [23]

Credit Life Plan (referring to an insurance plan purchased to protect a borrower)/ Pelan Hayat Kredit (merujuk kepada pelan insurans yang dibeli untuk melindungi peminjam) [27]

1.Estimated surrender value; and/ Anggaran nilai serahan; dan

2.Total indebtedness and total outstanding of the Policy/Insurance Certificate (where applicable)./ Jumlah keberhutangan dan jumlah tertunggak dari Polisi/Sijil Insurans ini (di mana terpakai).

PART 2: BANK ACCOUNT DETAILS * as appeared in the bank passbook or statement (Only applicable if you are applying for Direct Credit Facility for the first time or updating your bank account details)

BAHAGIAN 2: BUTIRAN AKAUN BANK* seperti yang tertera di dalam buku akaun bank atau penyata bank (Hanya terpakai jika anda memohon untuk kemudahan Kredit Terus untuk kali pertama atau mengemaskini butiran akaun bank anda)

Bank Name/ Nama Bank

Account Holder's Name/

 

 

 

Nama Pemegang Akaun

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Type/ Jenis Akaun

[

]

Conventional/ Konvensional

Bank Account No./ No. Akaun Bank

*Tick [√] where appropriate/ Tandakan

[

]

Islamic/ Islam

 

[√] pada kota yang berkenaan

 

 

 

 

 

 

 

 

 

NRIC No. (New)/NRIC No. (Old)/

Passport/Police/Army/Company

 

 

 

No. K/P (Baru)/No. K/P (Lama)

 

 

 

Registration No./ No.Pasport/Polis/

 

 

 

*As per bank account/ Seperti yang

 

 

 

Tentera/Pendaftaran Syarikat

 

 

 

tertera dalam akaun bank

 

 

 

 

 

 

 

Important Note:/ Nota Penting:

Please complete the Direct Credit section for arrangement for all the payouts from the policies listed in this form to be credited to the payee’s selected bank account. PAMB will pay all these payouts into the payee’s bank account that is registered with us. Otherwise, PAMB may consider relying on digital service or product, such as DuitNow to pay these payouts to the payee, only if such service or product is made available. If PAMB is not able to pay the monies

to the payee within a year from the date the monies first become payable, the monies will be regarded as unclaimed monies. If so, PAMB is required to lodge the unclaimed monies with Jabatan Akauntan Negara Malaysia./ Sila lengkapkan bahagian Kredit Terus untuk semua urusan pembayaran daripada polisi- polisi yang disenaraikan dalam borang ini ke dalam bank akaun pilihan penerima. PAMB akan membayar semua pembayaran ke dalam bank akaun penerima yang telah didaftarkan dengan PAMB. Kalau tidak ada, PAMB mungkin mempertimbangkan untuk bergantung kepada perkhidmatan atau produk digital, seperti DuitNow untuk membayar pembayaran kepada penerima, hanya jika perkhidmatan atau produk tersebut boleh digunakan. Jika PAMB tidak dapat membuat pembayaran dalam tempoh setahun dari tarikh pertama pembayaran kena dibayar, wang akan dianggap sebagai wang tidak dituntut. Maka, PAMB akan menyerahkan wang tidak dituntut kepada Jabatan Akauntan Negara Malaysia.

FORM ID 110010

Prudential Assurance Malaysia Berhad (107655-U)

 

Level 20, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur, Malaysia. P.O. Box 10025, 50700 Kuala Lumpur.

Version / Versi 06/2019

Customer Service Hotline: 603-2116 0228, Email: customer.mys@prudential.com.my

Page/ Mukasurat 1/3

Policy/Insurance Certificate Number/ Nombor Polisi/Sijil Insurans

PART 3: STATEMENT OF DECLARATION / BAHAGIAN 3: KENYATAAN PENGAKUAN

A. Surrender/ Serahan

1.I/We have read, understood and agreed to the Terms and Conditions (as set out below) for making this application./ Saya/Kami telah membaca, memahami dan bersetuju kepada Terma dan Syarat (seperti yang ternyata di bawah ini) untuk permohonan ini.

2.I/We understand that this application will not take effect until it is accepted and notified to me/us by Prudential Assurance Malaysia Berhad(“PAMB”)./ Saya/Kami memahami bahawa permohonan saya/kami tidak akan berkuatkuasa sehingga permohonan saya diterima dan dimaklumkan kepada saya/kami oleh Prudential Assurance MalaysiaBerhad (PAMB).

3.I/We declare that the information given in this form is true and complete./ Saya/Kami mengaku bahawa semua maklumat yang diberikan dalam borang ini adalah benar dan lengkap.

4.I/We understand that all requests received shall be processed based on the terms stated in the Policy/Insurance Certificate./ Saya/Kami memahami bahawa semua permohonan akan diproses mengikut terma yang tertera dalam Polisi/Sijil Insurans.

5.I/We further declare that I/we am/are not involved in any bankruptcy proceedings and that I/we have committed no act of bankruptcy in the last twelve (12) months and that no receiving order has been made against me/us nor have I/we been adjudged bankrupt during that period./ Saya/Kami selanjutnya mengaku bahawa saya/kami tidak terlibat di dalam apa‐apa prosiding kebankrapan dan saya/kami tidak melakukan perbuatan kebankrapan di dalam tempoh duabelas (12) bulan yang lalu dan tiada perintah penerimaan atau penghukuman kebankrapan telah dibuat ke atas saya/kami dalam tempoh tersebut.

B. Direct Credit (Only applicable if you are completing the Bank Account Details)/ Kredit Terus (Hanya terpakai jika anda melengkapkan Butiran Akaun Bank)

In consideration of PAMB approving this application, I/we, who am/are also the Payee, hereby agree and declare that:/ Sebagai balasan kepada PAMB membenarkan permohonan ini, saya/kami, yang mana saya/kami adalah seorang Penerima, dengan ini bersetuju dan mengisytiharkan bahawa:

1.PAMB shall pay and credit the relevant monies payable pursuant to the Proposal and Policy (“Monies”) into the Account;/ PAMB akan membayar

dan mengkreditkan wang yang relevan yang boleh dibayar menurut Cadangan dan Polisi (“Wang”) ke Akaun;

2.PAMB shall continue to pay/credit the Monies into the Account until and unless PAMB receives a written instruction from the Payee to revoke

the authority given to PAMB pursuant to this application or PAMB approves a new application to change the Account details provided in this application;/ PAMB akan terus membayar/mengkreditkan Wang tersebut ke dalam Akaun sehingga dan melainkan PAMB menerima arahan

bertulis daripada Penerima untuk menarik balik kuasa diberikan kepada PAMB menurut permohonan ini atau PAMB meluluskan permohonan yang baru untuk mengubah butiran Akaun diberikan dalam permohonan ini;

3.PAMB shall not be held liable for any losses that I/we may suffer or have suffered, whether directly or indirectly, if for any reason PAMB is unable or delayed to pay and credit the Monies into the Account through no fault of PAMB, including but not limited to, the payment being rejected by the financial institution due to incorrect Account details;/ PAMB tidak bertanggungjawab terhadap sebarang kerugian yang mungkin saya/kami tanggung atau telah tanggung, sama ada secara langsung atau tidak langsung, jika untuk sebarang sebab PAMB tidak dapat atau lewat membayar dan mengkreditkan Wang tersebut ke dalam Akaun atas sebab bukan salah PAMB, termasuk tetapi tidak terhad kepada bayaran ditolak oleh institusi kewangan kerana butiran Akaun yang tidak betul;

4.I/We agree to immediately refund to PAMB in full the Monies which is paid by mistake or which I/we am/are not entitled to receive;/ Saya/ Kami bersetuju untuk membayar balik dengan serta-merta dan secara penuh Wang tersebut yang telah tersalah bayar atau wang yang saya/kami

tidak ada hak untuk menerimanya;

5. PAMB is kept harmless and fully indemnified against any and all actions, claims, proceedings, costs (including legal costs on solicitor and client basis) and damages, including any compensation paid by PAMB to settle such claim, that may howsoever arise from or be incidental to my/our instruction pursuant to this application. This authorization and indemnity contained in this application shall be binding upon my/our respective successors-in-title, executors, administrators, personal representatives and/or heirs; and/ PAMB dilindungi dan dilepaskan secara sepenuhnya

daripada sebarang dan semua tindakan, tuntutan, prosiding, kos (termasuk kos perundangan atas dasar peguamcara dan pelanggan) serta kerugian, termasuk sebarang pampasan dibayar oleh PAMB untuk menyelesaikan tuntutan sedemikian, yang mungkin timbul dalam apa cara sekalipun daripada atau berkaitan dengan arahan saya/kami menurut permohonan ini. Pemberian kuasa dan tanggung rugi ini adalah mengikat ke atas pengganti hak milik, wasi, pentadbir dan wakil peribadi serta/atau waris saya/kami; dan

C. Data Privacy Declaration/ Pengakuan Data Peribadi

I/We understand and agree to the following Data Privacy Declaration:/ Saya/Kami faham dan bersetuju kepada Pengakuan Data Peribadi berikut:

1.Any personal data collected or held by PAMB (whether given now or subsequently to PAMB) can be processed and used to process this application, for data matching, fraud detection and prevention, discharging PAMB’s duties as an insurer, updating PAMB’s records, marketing and promotion of other financial products and services by PAMB, group of companies of PAMB and Prudential plc, as well as communicating with me/us for any of these purposes (“Purposes”);/ Sebarang data peribadi yang dikumpul dan dipegang oleh PAMB (sama ada yang diberikan sekarang atau pada masa hadapan kepada PAMB) boleh diproses dan digunakan untuk memproses permohonan ini, pemadanan data, mengesan dan mencegah frod, melaksanakan tugas-tugas PAMB sebagai syarikat insurans, mengemaskini rekod PAMB, pemasaran dan promosi produk dan perkhidmatan kewangan lain oleh PAMB, kumpulan syarikat bagi PAMB dan Prudential plc, serta berkomunikasi dengan saya/kami untuk mana-mana tujuan disebut di atas (“Tujuan-Tujuan”);

2.To achieve these Purposes, PAMB (and any third party appointed by PAMB) can transfer and disclose the personal data to third parties such as financial institutions, reinsurers, claims investigator companies, other insurers, industry associations, PAMB’s intermediaries, individuals or entities within PAMB, group of companies of PAMB and Prudential plcs, as well as other third party service providers PAMB has appointed. As some of these third parties are not located in Malaysia, PAMB can transfer the personal data to places outside of Malaysia;/ Bagi mencapai Tujuan-Tujuan di atas, PAMB (dan mana- mana pihak ketiga yang dilantik oleh PAMB) boleh memindah dan mendedahkan data peribadi kepada pihak-pihak ketiga seperti institusi kewangan, penanggung insurans semula, syarikat siasatan tuntutan, syarikat insurans lain, persatuan berkaitan dengan industri insurans, pihak pengantara bagi PAMB, individu atau entiti dalam PAMB, kumpulan syarikat bagi PAMB dan Prudential plc, dan juga pemberi perkhidmatan pihak ketiga lain yang telah dilantik oleh PAMB. Oleh sebab sesetengah pihak-pihak ketiga ini tidak terletak di dalam Malaysia, PAMB boleh memindahkan data peribadi tersebut ke tempat-tempat di luar Malaysia;

3.I/We understand that I/we have a right to get access and request for correction of any personal data held by PAMB. Such requests can be made at PAMB’s Customer Service Centre; and/ Saya/Kami faham bahawa saya/kami mempunyai hak untuk akses dan memohon pembetulan dibuat ke atas mana- mana data peribadi yang dipegang oleh PAMB. Permohonan tersebut boleh dibuat di Pusat Perkhidmatan Pelanggan PAMB; dan

FORM ID 110010

Prudential Assurance Malaysia Berhad (107655-U)

 

Level 20, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur, Malaysia. P.O. Box 10025, 50700 Kuala Lumpur.

Version / Versi 06/2019

Customer Service Hotline: 603-2116 0228, Email: customer.mys@prudential.com.my

Page/ Mukasurat 2/3

Policy/Insurance Certificate Number/ Nombor Polisi/Sijil Insurans

4.This Data Privacy Declaration can be revised from time to time, of which the notice of any such revision can be given on PAMB’s corporate website or by

such other means of communication deemed suitable by PAMB./ Pengakuan Data Peribadi ini boleh diubah dari semasa ke semasa, yang mana notis untuk sebarang pengubahan boleh diberi melalui laman korporat PAMB atau mana-mana cara komunikasi yang PAMB anggap sesuai.

I/We understand and agree that unless a longer period of document retention is required by law or PAMB’s internal policies, PAMB will only retain the original physical documents submitted to PAMB for 6 months from the date PAMB received that document. PAMB shall not be held liable for disposal of

such documents. Therefore, if I/we want the original physical document to be returned, I/we will have to submit the request to PAMB in the form PAMB decides within 3 months from the date PAMB first received that document./ Saya/Kami memahami dan bersetuju bahawa melainkan undang-undang atau polisi dalaman PAMB memerlukan tempoh penyimpanan dokumen yang lebih lama, PAMB hanya akan menyimpan dokumen fizikal asal yang diberi kepada PAMB untuk tempoh 6 bulan dari tarikh PAMB menerima dokumen tersebut. PAMB tidak akan bertanggungjawab atas pelupusan dokumen tersebut. Oleh itu, jika saya/kami ingin dokumen asal dikembalikan, saya/kami perlu memohon kepada PAMB melalui bentuk permohonan yang ditentukan oleh PAMB dalam masa 3 bulan dari tarikh pertama PAMB menerima dokumen tersebut.

Note: In the event of any ambiguity between the English and Bahasa Melayu version, the English version shall prevail and be given effect to.

Nota: Sekiranya terdapat ketidak-selarian antara versi Bahasa Inggeris dengan Bahasa Melayu, versi Bahasa Inggeris akan diutamakan dan dikuatkuasakan.

Signature of Assured/Assignee(if any)/Insured Member Tandatangan Pemunya Polisi/Penerima Hak (jika ada)/ Ahli Yang Diinsuranskan

Name/ Nama:

NRIC/Passport No./ No. Kad Pengenalan/Pasport:

Signature of Trustee(s) (if any)/ Tandatangan Pemegang Amanah (jika ada)

Name/ Nama:

NRIC/Passport No./ No. Kad Pengenalan/Pasport:

PART 4: STATEMENT OF WITNESS / BAHAGIAN 4: KENYATAAN SAKSI

I hereby certify the above signature(s) was/were made in

my

presence and that

to

my

own

personal

knowledge

it

is the

signature(s) of the Life Assured/Assured/Spouse/Parent/Legal Guardian/Joint

Parent/Assignee/Trustee(s)/Insured Member under the

Policy/Insured

Certificate mentioned

as above./ Saya dengan ini

mengesahkan

bahawa

tandatangan

di

atas

dibuat

di hadapan saya

dan

setakat

yang

saya ketahui

tandatangan tersebut ialah

tandatangan Hayat

Yang

Diinsuranskan/Pemunya

Polisi/Pasangan/Ibu

bapa/Penjaga

Sah/Ibu

bapa

Bersama/Penerima Hak/Pemegang Amanah/Ahli Yang Diinsuranskan di bawah Polisi/Sijil Insurans yang disebutkan di atas.

 

 

 

Note: The witness must be completed by an authorized Quality Agent, Quality Leader, Branch Head, Customer Service Representative or Bank

Representative of PAMB; or Commissioner for Oath or Notary Public./ Nota: Saksi mestilah seorang Ejen Berkualiti, Pemimpin Agensi, Ketua Cawangan, Wakil Khidmat Pelanggan atau Wakil Bank Kepada PAMB; Pesuruhjaya Sumpah atau Notari Awam.

Witness’s Name/ Nama Saksi:

NRIC/Passport No./ No. Kad Pengenalan/Pasport:

Signature of Witness / Tandatangan Saksi

PART 5: TERMS & CONDITIONS / BAHAGIAN 5: TERMA‐TERMA & SYARAT‐SYARAT

A. Application/Permohonan

1.Copy of identity card or passport of the Assured/Assignee/Insured Member (where applicable) must be enclosed./ Salinan kad pengenalan atau pasport Pemunya Polisi/Penerima Hak/Ahli Yang Diinsuranskan (di mana terpakai) mesti disertakan.

2.Only the original form duly completed by Assured/Assignee (if any)/Insured Member shall be acceptable./ Cuma salinan asal yang diisi oleh Pemunya Polisi/Penerima Hak (jika ada)/Ahli Yang Diinsuranskan akan diterima.

3.Consent from Trustee(s) is required./ Kebenaran dari Pemegang Amanah adalahdikehendaki.

B.Application For Surrender/ Permohonan Untuk Serahan

1.The surrender value will be determined in accordance with the Policy/Insurance Certificate and other such documentation required by PAMB to prove the title of the person claiming payment./ Nilai serahan akan ditentukan menurut Polisi/Sijil Insurans tersebut dan dokumen lain yang dikehendaki oleh PAMB bagi mengesahkan hak milik individu yang menuntutbayaran.

2.The surrender value payable is subject to the surrender charge, redemption cost, tax penalty or any other charges provided under the Policy/Insurance Certificate (where applicable) (collectively refered to as the “Surrender Related Charges”) and any of the Surrender Related Charges can be varied from time to time./ Nilai serahan yang perlu dibayar adalah tertakluk kepada caj serahan, kos penebusan, penalti cukai atau apa apa caj lain yang diberikan di bawah Polisi/ Sijil Insurans (di mana terpakai), (secara kolektif dirujuk sebagai "Caj Tentang Serahan) dan mana-mana Caj Tentang Serahan ini boleh diubah dari semasa ke semasa.

3.No reinstatement is allowed./ Pengembalian semula tidak dibenarkan.

4.The Surrender Value is referring to the amount provided under the Policy/Insurance Certificate, less any amount owed to PAMB including but not limited to the Surrender Related Charges./ Nilai Serahan merujuk kepada amaun yang diperuntukkan di bawah Polisi/Sijil Insurans, yang mana amaun tersebut akan ditolak dengan sebarang amaun yang terhutang kepada PAMB termasuk tetapi tidak terhad kepada Caj Tentang Serahan.

5.The Policy/Insurance Certificate and any premium payment facility will be terminated upon surrender./ Polisi/Sijil Insurans dan sebarang kemudahan pembayaran premium akan ditamatkan setelah serahan.

6.PAMB will only process this Application after the completion of any prior request for top-up and prior premium payments./ PAMB hanya akan memproses Permohonan ini selepas sebarang permintaan untuk pembayaran premium tokokan dan premium terdahulu telah dilengkapkan.

FORM ID 110010

Prudential Assurance Malaysia Berhad (107655-U)

 

Level 20, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur, Malaysia. P.O. Box 10025, 50700 Kuala Lumpur.

Version / Versi 06/2019

Customer Service Hotline: 603-2116 0228, Email: customer.mys@prudential.com.my

Page/ Mukasurat 3/3

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