Request To Cancel Policy Form

Request To Cancel Policy Form
We/I understand that the bank has discharged its interest in this policy. We/I would like to cancel our/my Mapfre MSV Life Protection Plan with immediate effect or the date of release of the bank’s interest, if this has not been done yet.

We understand that for a cancelled policy to be eligible for a premium refund, it should meet the following criteria:
- The premium refund following a request of cancellation of policy after the premium has been paid will be calculated on a pro-rata basis taking into account the number of days of unexpired cover. Refunds are not applicable for policies that are paid monthly.
- The date of cancellation will be either the date when we receive a request; or the date of the pledge discharge, whatever is the latest.
- There is an administration charge of €15 unless cancellation is done within the same month where the premium is due. Any payments made by cheque will incur a €5.00 charge which will be deducted from the amount payable
- MAPFRE MSV Life retains the right (in exceptional circumstances) not to pay refunds.
- Payments below €10 (after deducting the relative charges) are not subject to a refund.
- Cheque Payments of €20 or under cannot be issued.

Policy Owner Details
Policy Number*
Policy Owner*

First NameLast Name
ID Card Number*
Policy Owner
ID Card Document Number*
Please note that this is not your ID card number, however it is the document number which is located at the back of your ID card (for newer ID cards, this is located at the front)
ID Card Expiry Date*
Month/Year
Mobile Number*
Email*
example@example.com
Occupation*
Is there a second policy owner?*

YesNo
Second Policy Owner*

First NameLast Name
ID Card Number*
Policy Owner
ID Card Document Number*
Please note that this is not your ID card number, however it is the document number which is located at the back of your ID card (for newer ID cards, this is located at the front)
ID Card Expiry Date*
Month/Year
Mobile Number*
Email*
example@example.com
Occupation*
Reason for cancellation

Policy Owner Self-Certification

Foreign Account Tax Compliance Act (FATCA) and OECD Common Reporting Standard (CRS) Tax Certification Individuals Self-Certification
We are obliged under Regulation 123.127 entitled “cooperation with other jurisdiction on tax matters” to collect certain information about each policy owner’s tax arrangements. Please complete the sections below as directed and provided. Please note that if your citizenship or your tax residence are not Maltese, MAPFRE MSV Life plc (MAPFRE MSV) may be legally obliged to pass on your details and other financial information with respect to all policies held with MAPFRE MSV to the Inland Revenue and they may exchange this information with tax authorities of another jurisdiction(s) pursuant to intergovernmental agreements to exchange financial account information. If any of the information below about your residence or FATCA/CRS Classification changes in the future, you are obliged to advise of these changes promptly. For more information on FATCA & CRS you can access MAPFRE MSV’s website. IMPORTANT NOTE Please complete all sections below, you are kindly requested to answer each question and clearly provide additional information where necessary and when you have answered “Yes” to any of the questions. Failure to supply full details will cause unnecessary delays.
Place Of Birth*
Place Of Work*
Nationality*
Second Country of Residence
Do you hold Dual Citizenship?*

YesNo
Other Nationality*
Tax Identification Each jurisdiction has its own rules for defining tax residence. In general, you may find that tax residence is the country/jurisdiction in which you live. Special circumstances may cause you to be resident elsewhere or resident in more than one country/jurisdiction at the same time (dual residency). For more information on FATCA and CRS please refer to Inland Revenue Malta website, the OECD CRS portal or consult your tax adviser. Please complete the following table indicating (i) where the Policy Owner is tax resident and (ii) the Policy Holder’s TIN for each country/jurisdiction indicated. If one of your tax residences is Malta, your Maltese TIN is your I.D. Card Number. If a TIN is unavailable, please provide the appropriate reason A, B or C where indicated below:
- Reason A – The country/jurisdiction where the Policy Owner is resident does not issue TINs to its residents.
- Reason B – The Policy Owner is otherwise unable to obtain a TIN or equivalent number (please explain why if you have selected this reason).
- Reason C – No TIN is required (NB. Only select this reason if the domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction)
Tax Identification*
Permanent Address*

Street Address

Street Address Line 2

CityTown

Post CodeCountry
Would you like our correspondence to go to an alternative address?*

YesNo
Correspondence Address*

Street Address

Street Address Line 2

CityTown

Post CodeCountry
Have you or any associated legal body been subject to the imposition of local or international Sanctions?

YesNo
Sanction*
Reason*

Second Policy Owner Self-Certification

Foreign Account Tax Compliance Act (FATCA) and OECD Common Reporting Standard (CRS) Tax Certification Individuals Self-Certification
We are obliged under Regulation 123.127 entitled “cooperation with other jurisdiction on tax matters” to collect certain information about each policy owner’s tax arrangements. Please complete the sections below as directed and provided. Please note that if your citizenship or your tax residence are not Maltese, MAPFRE MSV Life plc (MAPFRE MSV) may be legally obliged to pass on your details and other financial information with respect to all policies held with MAPFRE MSV to the Inland Revenue and they may exchange this information with tax authorities of another jurisdiction(s) pursuant to intergovernmental agreements to exchange financial account information. If any of the information below about your residence or FATCA/CRS Classification changes in the future, you are obliged to advise of these changes promptly. For more information on FATCA & CRS you can access MAPFRE MSV’s website. IMPORTANT NOTE Please complete all sections below, you are kindly requested to answer each question and clearly provide additional information where necessary and when you have answered “Yes” to any of the questions. Failure to supply full details will cause unnecessary delays.
Place Of Birth*
Place Of Work*
Nationality*
Second Country Of Residence
Do you hold Dual Citizenship?*

YesNo
Other Nationality*
Tax Identification Each jurisdiction has its own rules for defining tax residence. In general, you may find that tax residence is the country/jurisdiction in which you live. Special circumstances may cause you to be resident elsewhere or resident in more than one country/jurisdiction at the same time (dual residency). For more information on FATCA and CRS please refer to Inland Revenue Malta website, the OECD CRS portal or consult your tax adviser. Please complete the following table indicating (i) where the Policy Owner is tax resident and (ii) the Policy Holder’s TIN for each country/jurisdiction indicated. If one of your tax residences is Malta, your Maltese TIN is your I.D. Card Number. If a TIN is unavailable, please provide the appropriate reason A, B or C where indicated below:
- Reason A – The country/jurisdiction where the Policy Owner is resident does not issue TINs to its residents.
- Reason B – The Policy Owner is otherwise unable to obtain a TIN or equivalent number (please explain why if you have selected this reason).
- Reason C – No TIN is required (NB. Only select this reason if the domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction)
Tax Identification*
Permanent Address*

Street Address

Street Address Line 2

CityTown

Post CodeCountry
Would you like our correspondence to go to an alternative address?*

YesNo
Correspondence Address*

Street Address

Street Address Line 2

CityTown

Post CodeCountry
Have you or any associated legal body been subject to the imposition of local or international Sanctions?

YesNo
Sanction*
Reason*

Payment details
Payment method details*

Direct credit to bankCheque
Any payments made by cheque will incur a €5.00 charge which will be deducted from the amount payable
MAPFRE MSV will only credit Bank Accounts held in the Policy Owner's name
Please provide your IBAN number*
Account Holder Name*
Bank*
Branch
MAPFRE MSV will only issue a cheque payable to the registered Policy Owners
Cheque issued in favor of *

First NameLast Name
Cheque issued in favor of (Joint policy holder details)*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCountry

Post CodeCountry

Signatures
We/I agree to indemnify MAPFRE MSV Life p.l.c., against all or any claims, losses, damages or costs of whatsoever nature suffered by the Company arising out of the use or misuse of the said policy by unauthrised persons. Upon cancellation of this policy, the policy document becomes null and void.
Date of submission*

DayMonthYear
Date
Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/table)*

YesNo
Signature of policy holder*
Signature of second policy holder, beneficiary*
Please upload images of the policy holder's, ID Card front and back*

Cancelof
Please upload images of the second policy holder's, ID Card front and back*

Cancelof
Should be Empty:

Request To Cancel Policy Form

Policy Owner Details

Policy Owner Self-Certification

Second Policy Owner Self-Certification

Payment details

Signatures