The cancellation of your insurance policy, and the protection it provides you, could be irreversible. You should consider your current
health status, age and financial position as you may be unable to obtain the same cover or may even have to pay substantially more if
you require protection in the future. You may be subject to health assessment and acceptance by the insurer, and you may not qualify
for cover if you decide to restart your cover in future. When you cancel, we will stop deducting premiums from your account. After
your cover has been cancelled, you should be aware you will not be able to make a claim for a condition that arises after the cover is
cancelled. We recommend that you consult financial adviser to help you make a decision before cancelling your policy. Your adviser
can explain the financial implications of cancelling your policy and how it may impact you and your family’s circumstances.
If you would like the contact details for your adviser, or to talk to one of our specialists about the flexible options you have, please call
us on 13 1056.
Instructions: Complete this form using a pen. Post the completed and signed form to: CommInsure. PO Box 320, Silverwater,
NSW, 2128. Alternatively you can scan and email the form to, or fax to F: 1300 852 076. If you have
any questions please contact CommInsure on 13 1056.
I have read and understood this section, including the explanation of the risks of cancelling my policy
Section 1 – Policy owner(s) (one owner to complete this section to identify the correct policy, then all to sign section 3)
Policy owner title Mr
Mrs Miss Ms Other
Member/ Policy owner full names
Policy owner date of birth (dd/mm/yyyy) Policy owner contact mobile
Policy owner email
Policy owner address
Suburb State Postcode
Section 2 – Policy number(s)
Section 3 – Policy owner signature (all owners are required to sign)
Cancel My Policy
Use this form for cancellation of entire policy
Position in company if policy owner one is a company Signature of policy owner one Date
Position in company if policy owner two is a company Signature of policy owner two Date
006-007 050520
‘CommInsure’ is used under licence by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
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