AMENDMENT FORM
Tel: 0303964782 Email: customerserviceheadoffice@gnlifeassurance.com
POLICY NUMBER (in CAPS)*
POLICY HOLDER’S NAME
Last Name First Name Other Name(s)
Phone Number
Email
example@example.com
Premium Category
Payment Options (Bank, Mobile Money)
Bank Mobile Money
Vendor*
Momo Number*
Momo Account Name*
First Names Last Name
Bank Name*
Bank Branch
Bank Account Number*
Bank Account Name*
First Name Last Name
Preferred Authorization*
Signature Thumb print
Signature*
Clear
Take Photo of Thumb Print*
Take Photo of ID Card
Financial Advisor (FA)
Completed By*
First Name Last Name
Should be Empty:

AMENDMENT FORM