Change Of Details Form
ADVERTISEMENT
1
2Change of details form
Insurance only
Important: Please provide us with as much information as possible. Before returning to Zurich, ensure this form is signed and dated.
To update details for a second policy owner, please complete a separate form.
Policy number/s
Policy owner
1
Please complete this section using the details we currently hold for you.
Title
Surname
Given name(s)
Residential address (cannot be a PO Box)
State
Postcode
Postal address (if different to residential address)
State
Postcode
Contact details
Work (
)
Home (
)
Mobile
Email
2
Updated name details (if different to above)
Please complete this section with your new details if you have changed your name. You must also sign below using your previous and new
signature to allow Zurich to process your request.
Title
Surname
Given name(s)
New signature
Previous signature
Please note where there has been a change to your name, you must provide certified evidence of the name change (eg certified copy of your
marriage certificate, divorce certificate or change of name certificate). Details of who can certify documents can be found in Section 5 of
this form.
3
Updated contact details (if different to above)
Please complete this section with your new details if they have changed.
Residential address (cannot be a PO Box)
State
Postcode
Postal address (if different to residential address)
State
Postcode
Contact details
Work (
)
Home (
)
Mobile
Email
4
Declaration
Please read and complete the following:
•
I declare that all the details on this Change of details form are correct and authorise the changes to be made to my policy/ies.
Date
Signature of policy owner
/
/
Zurich Australia Limited ABN 92 000 010 195, AFSL 232510
Change of details form – Page 1 of 2
5 Blue Street North Sydney NSW 2060.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal