Change Of Address/contact Details
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2*CHGID*
Change of Address / Contact Details
Part A
Your details
►Please tick one
Mr
Mrs
Mdm
Ms
Dr
Name ► As in NRIC / Passport
NRIC / Passport number
______________________________________________________________________
_________________________________________
Part B
Your new address
Update of Residential Address
Update of Mailing Address (if different from Residential Address)
________________________________________________________
_______________________________________________________
__________________________________ Postal Code _________
_________________________________ Postal Code _________
Your correspondences for all policies / accounts with Aviva will be
Update all my policies / accounts with Aviva
sent to this new residential address. If you wish to receive your
Update Life and Health Insurance plan(s) only
correspondences at another address for any of your policies, please
Update General Insurance plan(s) only
complete Update of Mailing Address portion.
Update the following policy / policies / accounts only
(Please list policy numbers below)
_______________________________________________________
Note: Proof of address is required for overseas address.
Part C
Your new contact details
New mobile number
New office number
New fax number
____________________________________
____________________________________
____________________________________
New home number
New email address
____________________________________
___________________________________________________________________________
Part D
Your declaration / authorisation
Declaration of US Indicia (This portion needs to be completed by Assured/Assignee/Trustee)
Do you have one or more US Indicia*?
Yes
No
Do you give standing instructions to transfer funds to an account maintained in the US?
Yes
No
Do you give effective power of attorney or signatory granted to a person with a US address?
Yes
No
If yes, please complete the United States of America (US) Person Declaration form (available at
downloads.html) and return to Aviva.
*US Resident / Citizen / Place of Birth / Taxpayer ID number / Mailing or Residential Address / Contact Number/US “in-care-of” or “hold mail”
address
Signature of Assured/Assignee /Trustee
Mobile number
Date
► Your signature must be consistent with our record
► DD/MM/YY
Email address
Notes:
a)
Mobile number and email address provided under Part D will replace our records accordingly.
b)
As a precaution against unauthorised changes to addresses, acknowledgements will be sent to both new and old addresses.
PSCLT001.01 (062016)
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