L_APP_CHANGE-NAME_12/17
Apply
for Policy number
Change of Name Notification
Please ck the appropriate boxes
Change of name by marriage/civil union Change of name by Deed Poll Name incorrectly recorded
Other (please specify)
Please attach copies of supporting documents to this form, such as a copy of your Marriage Certificate,
Birth Certificate or New Zealand Driver’s Licence.
*
3.0 Reason for name change
4.0 Current details
Number
Street Name
Rural
Delivery No.
Town/City
Suburb
Postcode
PO Box Private Bag Street Number
Email Address
1.0 Your previous details
Name as currently recorded by Partners Life
Mr
Mrs
Miss
Date of Birth
Date of Birth
First
Name
Middle
Name(s)
Surname
D
D
D
D
M
M
M
M
Y
Y
Y
Y
Previous signature
Date
D D M M Y Y
2.0 Your new details
New name to be recorded by Partners Life
Mr
Mrs
Miss
First
Name
Middle
Name(s)
Surname
New signature
Date
D D M M Y Y
Scan and email to service@partnerslife.co.nz or post to:
Partners Life Limited, Private Bag 300995, Albany, Auckland 0752, New Zealand | 0800 14 54 33 | partnerslife.co.nz
Second policy owner’s name/company details
Signature/authorised signature of second policy owner
Date
D D M M Y
First policy owner’s name/company details
Signature/authorised signature of rst policy owner
Date
D D M M Y Y
Y
Other
Other
Male
Male
Female
Female
