alteration form - takaful - adamjee life€¦ · change of funds/change of portfolio details...

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Page 1 of 2 ALTERATION FORM Change in Spelling of Certificate Owner / Person covered Name/CNIC/Account/Address/Contact/Email Change in Date of Birth Change in Beneficiary /Guardian Details Change in Contribution Mode ا� م اور د�ر�� / Particulars Existing/Old Required/New First Name Middle Name Last Name Certificate Owner Person Covered CNIC # Account # Address Contact # Email م م در� م ى� آ� م مرڈ �ؤ� ا� را� ر� ا� اىا�� / ى/ � ن/ وار�Name Of Beneficiary Date Of Birth Relationship With Person Covered Guardian �ى ا� ر� ر� د� �رّ زرCertificate Owner Male Person Covered Female Person Covered Beneficiary Date Of Birth ا� ر��ر �د �رت �ى ا� ر�Contribution Mode Monthly Quarterly Semi Annually Annually Benefits Sum Assured Term Sum Assured Term Add/Deletion Rider Basic Plan Term Family Takaful Monthly Income Supplementary Benifit Waiver Of Contribution Disability Accidental Death & Disability Benefit Critical Illness Benifit Spouse Supplementary Benifit Accidental Death Benifit Others ادا�دى �ن �مت و �ورىد� ا�ّ ا�ّ ت و�ورىد� ا�ّ ك ا�اض ا�ّ ّ ت� �ر �تد� ا�ّ د�ر� ادا�� / ا�رم �ا� در�Existing New درج �ہ �ہ� / Share Percentage - ا��دہ ر� من�رڈ � را�Contribution Contribution Adamjee Life - WIndow Takaful Operations The Forum, Suite No. 323, 3rd Floor, Plot G-20, Block 9, Clifton, Karachi - 75600 PAKISTAN Date / : ____________ Plan / : ____________ Email Address / : ______________________________________________________________________________________ CNIC / : _____________________________ Contact Number / : __________________ Certificate Number / : ___________ Name of Participant / : _________________________ ADAMJEE LIFE ASSURANCE CO. LTD WINDOW TAKAFUL OPERATIONS

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Page 1: Alteration form - Takaful - Adamjee Life€¦ · Change Of Funds/Change Of Portfolio Details Declaration (Only Complete this section if you would like to direct contributions/premiums

Page 1 of 2

ALTERATION FORM

Change in Spelling of Certificate Owner / Person covered Name/CNIC/Account/Address/Contact/Email

Change in Date of Birth

Change in Beneficiary /Guardian Details

Change in Contribution Mode

���   ��  � �

�ا�  � د�� اور  �م  ��  � ��ر    ��� ���� �� �� / ��   ���

Particulars Existing/Old Required/New First Name Middle Name Last Name Certificate Owner Person Covered CNIC # Account # Address Contact # Email

�م ��  ��م ��  �� در���م �� �ى 

�آ�

�م ��  �  �  �   ��� ���� �� ��

�م ��  �  ��   ���

� �رڈ   ���   �

�ا�ؤ�   � � ��

� را� �ر�� � ا��  ���� اى 

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�ا�  � / ��ى/ ����� �� ��� �

�� �ن/ ���� وار��

Name Of Beneficiary Date Of Birth Relationship With Person Covered

Guardian

��ى � �� ��� �

�� ����

�ا� � ��  � ��ر� ��

ر�  �� �د� �

�   ��� ������� �

���ر��

�ّ   ��  ����� � زر ����

Certificate Owner Male Person Covered Female Person Covered Beneficiary Date Of Birth

���   �� �ا�  � ��  � ��ر� ��

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�د  ��   ���

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��ى� �� ��� �

�� ����

�ا� � ��  � ��ر� ��

Contribution Mode Monthly Quarterly Semi Annually Annually

Benefits Sum Assured

Term

Sum Assured Term

Add/Deletion Rider

Basic Plan Term Family Takaful

Monthly Income Supplementary Benifit Waiver Of Contribution Disability Accidental Death & Disability Benefit Critical Illness Benifit Spouse Supplementary Benifit Accidental Death Benifit Others

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� ��  �

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�  �

و�ورى �ت   �� �د�� �ا�  ��   � ّ� �

�  �ا�اض �ك  ��� �ا�  ��   � ّ

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� ّ� �

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�  �

� د��

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ادا�  �  �� � � ���

����� / ��� �ا�  �� �رم    در�ا��

Existing New

�ہ درج    ��   ����� �ہ   ����� / � �

��

Share Percentage -

�ا�  �   ��

�  �  ����دہ ��

��

� ��ر� �� �   ��� ���� �

� �� ��   ����م ��  � �ن  � �رڈ   �� � را� 

�  �  �  �� ��

Contribution Contribution

Adamjee Life - WIndow Takaful OperationsThe Forum, Suite No. 323, 3rd Floor, Plot G-20,Block 9, Clifton, Karachi - 75600 PAKISTAN

Date / : ____________

Plan / : ____________

Email Address / : ______________________________________________________________________________________

CNIC / : _____________________________ Contact Number / : __________________

Certificate Number / : ___________ Name of Participant / : _________________________

ADAMJEE LIFE ASSURANCE CO. LTDWINDOW TAKAFUL OPERATIONS

Page 2: Alteration form - Takaful - Adamjee Life€¦ · Change Of Funds/Change Of Portfolio Details Declaration (Only Complete this section if you would like to direct contributions/premiums

Change Of Funds/Change Of Portfolio Details

Declaration

(Only Complete this section if you would like to direct contributions/premiums to a new portfolio of Fund)

Name Of Current Fund Name Of Fund Required

***The change of fund strictly depend upon the flexibility and nature of fund.

***The change of fund will be at the entire discretion of the company.

For Details of Funds, Please to the refer website: www.adamjeelife.com

Declaration of health

Details of change in Health, Occupation and Residence Change in :

Health Status Occupation Residence

Yes No Yes No Yes No

I have understood the meaning and scope of the change request form and take complete responsibility of the changes submitted by my self. I accept the fact that any changes in the certificate / personal details are subject to the certificate terms and conditions and the relevant underwriting guidelines. I do hereby declare that the foregoing statement and answers are true and complete in every particular, and agree and declare that these statements and this is declaration along with my Takaful Certificate shall be the basis of the contract of certificate between Adamjee Life Window Takaful Operations and my self, and that if any untrue averment be contained therein, the said contract shall be null void and all money which shall have been paid in respect thereof, shall stand forfeited in favour Adamjee Life Window Takaful Operations.

________________________________Signature of Participant Owner

________________________________

Adamjee Life - Window Takaful Operation Approval

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�م ��  �  � ��دہ  �ں  ��  � ���  �� آپ   �   ���  � ��� �م  ��  �  � اس 

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��  �  � www.adamjeelife.com

***

***

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Page 2 of 2

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