Get Assupol Cancellation Form

You may also call the Assupol Demutualisation Call Centre on 0861 84 84 44 to confirm your particulars telephonically. ASSUPOL DEMUTUALISATION CONFIRMATION FORM More than R900 million in your hands Why must I complete this confirmation form As part of the scheme for the demutualisation of Assupol you need to confirm your particulars. Signature of policyholder d Date I would like to be contacted about a new policy Yes m y No For more info about our demutualisation Call us on 0861 84 84 44 or visit our website www. assupol.co. za For office use Checked by Manager Assupol Holdings Ltd reg no 2010/015888/06 PO Box 35900 Menlo Park Pretoria 0102 308 Brooks street Menlo Park Pretoria 0081. You must confirm your particulars requested in this form as soon as possible. If you do not confirm your particulars you will forfeit any entitlement you have in terms of the demutualisation scheme. What must you do as part of the confirmation process Complete and submit this form at any Assupol branch office or the Assupol head office or hand it to your Assupol sales representative. Assupol will confirm your status as a qualifying member. After you received a notification confirming your status as a qualifying member Assupol will send you a share allocation summary indicating the number of free shares allocated to you as well as the cash value. ID number Surname Initials Postal address Postal code Tel no w Cellular Fax no Email address Please provide your bank account into which account the demutualisation pay-out can be made. This information will enable Assupol to establish whether you are a qualifying member entitled to the allocation of free shares. The free shares have a monetary value and have since been exchanged for cash which will entitle you to a cash payout if you are a qualifying member. You must confirm your particulars requested in this form as soon as possible. If you do not confirm your particulars you will forfeit any entitlement you have in terms of the demutualisation scheme. This information will enable Assupol to establish whether you are a qualifying member entitled to the allocation of free shares. The free shares have a monetary value and have since been exchanged for cash which will entitle you to a cash payout if you are a qualifying member. You must confirm your particulars requested in this form as soon as possible. If you do not confirm your particulars you will forfeit any entitlement you have in terms of the demutualisation scheme. What must you do as part of the confirmation process Complete and submit this form at any Assupol branch office or the Assupol head office or hand it to your Assupol sales representative. You may not complete this form on behalf of another person* Very important to note Only qualifying members will be entitled to a cash pay-out. Assupol will confirm your status as a qualifying member. After you received a notification confirming your status as a qualifying member Assupol will send you a share allocation summary indicating the number of free shares allocated to you as well as the cash value..