CHANGE OF SERVICING AGENT (INTERMEDIARY) FORM


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POLICY INFORMATION (FOR POLICYHOLDER ONLY)

CHANGE OF SERVICING REQUEST

I would like to appoint the following servicing agent (intermediary) with immediate effect.

NEW AGENT (Intermediary)
SOMPO INSURANCE SINGAPORE PTE. LTD. (as direct customer)

This request applies to:

ALL my existing policy(ies) with Sompo Insurance Pte. Ltd.
The policy(ies) listed below (state policy number):

*Please release the relevant policy information to my newly appointed intermediary for his/her easy reference.

ACKNOWLEDGEMENT FROM POLICYHOLDER

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