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Ref. PS/Claim/Maturity Date To, (To be completed by the Life Assured/Proposer under a policy which has matured for payment and policy document has been misplaced or lost by him) Matured Policy No.
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? 4 Have you received any Invoice in respect of payment of the Premium / Premium Interest? If yes, (e.g. from the issuer), what was the amount thereof ? 5 How was the policy treated in respect of premium paid ? 6 Do the policyholders have sufficient evidence of the amount of premium paid per annum by them for the life of the policy? If 'no', do you have any of your own ? 7 Is the Policy still active? If 'no', was it cancelled ? If 'yes', what is the date of its cancellation ? 8 What is the policyholder's name? 9 What is the policyholder's home address? 10 Are the policyholders in financial distress? If so, what have been the status of their finances since the date of application for life assurance? 11 Has the policy been cancelled and written of? 12 Is the claim made in relation to which the claimant has been entitled to surrender the policy (which is, not paid)? 13 Has the policyholder, or his Representative, made a claim for life assurance in any other manner? 14 Have you received any evidence in respect of the application for policy surrender ? 15 I have received the surrender of my policy or would like to surrender my policy as a surrender ? 16 If the policy is cancelled , what is the period for which it is cancelled ? 17 If your policy has been cancelled, why has it been cancelled ? 18 Please give any particulars or information which can aid me in my investigation of the incident. 19 Have we previously exchanged any information/evidence with any other Government Officer or department? 20 Does this incident (if applicable to the current application and to any previous applications) have any precedents ? Your Name Address (include post code if applicable) Telephone e-mail Your Reply Your Name Address (including post code if applicable) Telephone e-mail Your Reply I hereby consent to the entry of any information received about me by the Information Commissioner and the disclosure of the same to: 1 Government Officer's Office PO Box 50 Newcastle upon Tyne NE16 8QY Fax 020 9365 4567 Email firstname.lastname@example.org (I am exempt from disclosing my address to Government Officers) I also confirm that I have read Privacy and Electronic Communications Regulations 2003, Part 5 and I confirm that I am not subject to any requirement to disclose my personal data
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