NTUC INCOME

REQUEST CHANGE OF INSURANCE ADVISER

To: Manager, Distribution Support

I, ____________________________________________, NRIC ______________________

(Name/NRIC of Policyholder – only policyholder is allowed to request for the change)

authorise you to effect a Change of NTUC Income Insurance Adviser with immediate effect

to ___________________________________, agent code __________________ for

1. ( ) Life Policy Number

2. ( ) My General / Commercial Insurance Policy Number

3a. ( ) My Medical Insurance Policy Number

3b. ( ) To include my Dependants under my policy

IMPORTANT Note : Policy number MUST be provided otherwise change will NOT be effected.

I understand and agreed to this change of insurance adviser request for the above

mentioned policies is at my own accord.

_______________________________________ ____________________________

Signature of Policyholder Date

(For Company name, please include Company stamp)

Policyholder’s contact no.:______________________ Email ________________________