Group Insurance Surrender Form
Group Policy Number
Plan Name
Employer/Group Name
Contact Number
Email Address
Member Details
Full Name
Membership/Employee No.
Date of Birth
Address
Reason for Surrender
Bank Details for Payment (if applicable)
Account Name
Bank Name
Account Number
IFSC/Swift Code
I confirm that the above information is true and request the surrender of my group insurance policy as detailed above.
Signature of Member
Date
Authorized Group Representative (if required)