Commonwealth Consolidated Regulations Commonwealth Consolidated RegulationsForm 2 Memorandum of transfer for assigning
rights
under a life policy
|
Date of transfer |
Signature of transferor |
Signature of transferor's witness |
Full name of transferee |
Address of transferee |
Occupation of transferee |
Signature of transferee |
Signature of witness of transferee |
Date of transfer of registration by the life company |
Signature of principal executive (or authorised person) of the life company |
Form 3 Statement of unclaimed money
(paragraph 10.05A (2) (a))
Year ended:
Company:
Contact officer:
Telephone:
|
Policy number |
Life insured: surname, given names, address |
Policy owner: surname, given names, address |
Amount due |
Date amount became due |
State where policy registered |
Signed: Dated:
(Principal Executive Officer of the life company or a person authorised by the Principal Executive Officer)
Form 4 Statement of money paid after the end of the calendar year
(paragraph 10.05A (3) (a))
Year ended:
Company:
Contact officer:
Telephone:
|
Policy number |
Claimant: surname, given names |
Date claimed |
Date paid |
Amount paid |
Signed: Dated:
(Principal Executive Officer of the life company or a person authorised by the Principal Executive Officer)
Form 5 Unclaimed money disk lodgment form
(subregulation 10.05A (4))
Unclaimed money for year ended:
Company:
Return address:
Contact officer:
Telephone:
Number of disks:
Creation date:
Original or replacement:
|
|
Number |
Value |
Unclaimed policies at the end of the year:
Policies claimed since the end of the year:
Certification: The information contained on the accompanying disks is that required by section 216 of the Life Insurance Act 1995 as the statement of unclaimed money, and money paid after the end of the calendar year.
Signed: Dated:
(Principal Executive Officer of the life company or a person authorised by the Principal Executive Officer)