Vanguard Life - Refund Claim

REFUND CLAIM FORM

FILL FORMS IN BLOCK LETTERS
Date

MonthDayYear
Date
Policy Number:
Name

First NameLast Name
Email
example@example.com
Address
Phone Number
Please enter a valid phone number.
Premium Payment Bank/Paypoint
Staff Id
Premium: GHC
Date of Maturity/Surrender/Age 65

MonthDayYear
Date
Refund Period: To
Pay me through

BankChequeMobile
Kindly terminate premium deduction

Tick if you wish to
Name of Bank / Momo Account Name
Branch
Account Number / Momo Number
Refund Type(Please Tick)

Deduction after MaturityDeduction after SurrenderOver DeductionWrongful DeductionUncredited PremiumOthers
Signature of Policyholder (Claimant)

Clear
Should be Empty:

REFUND CLAIM FORM