DECLARATION FORM

To Date: DD / MM / YYYY
Max Life Insurance Company Limited

Proposal Form Number: 

Name Mismatch:

I hereby declare that the name on the application form < Name on application form >and the name on

supporting document < Name of the document >, < Name on supporting document > are correct

and can be used interchangeably. For your records and my Max Life Policy, please use

< Name to be printed on policy details >.

Date of Birth Mismatch

I hereby declare my Date of Birth is <Date of Birth as per supporting document provided> as per

<Name of the supporting document provided>

Customer Sign:

Date: .