TRANSFER SERVICING RIGHTS

TRANSFER SERVICING RIGHTS
8/130 Main Road, McLaren Vale SA 5171 PO Box 265, McLaren Vale SA 5171

PH: 1300 160 803
TO WHOM IT MAY CONCERN
I/we authorise the servicing rights of my/our financial products be transferred to:
Product Provider*
Adviser Code
I/we understand that the appointed adviser and their Licensee will:
- be responsible for providing me/us with ongoing advice relating to this policy/contract, and receive any remuneration currently being paid for this policy following the transfer.
- Until the transfer is finalised I authorise the following persons to have access to my/our policy/contract information:
Harpinder Chipra
Marek Lambert
Ethel Caballero
Janine Towill
Name*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Policy/Account No.
Date*

MonthDayYear
Date
How is this form to be completed?

Signed electronically via docusign in personSigned digitally or printed
Signature*

Clear
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