Who is this form for?
This form is for individual, trustee and corporate policyholders of a PIMS policy. It allows you to authorise RL360 to deduct a valuation
fee for a valuation statement that is requested by a third-party, and in addition to the scheduled valuation statements we provide.
Completing this form
By completing this form you will be allowing a third-party (usually your Financial Adviser, Investment Adviser or Discretionary
Manager) to receive a valuation statement, for which RL360 will deduct a valuation fee.
We can only accept original written instructions by post that have been signed by all individual policyholders, trustees or
authorised signatories. We will not accept instructions by email or fax.
Please complete in BLOCK capitals throughout.
Important information
The valuation fee is a fixed amount as detailed in your product literature, and on our website. The fee is deducted from the
policy cash account on the date the valuation statement is issued.
Valuation statements are available for download, free of charge, by registering for our Online Service Centre. Please contact us
on +44 (0)1624 681682 or by email to for further details on how to register.
Please return this form to: Customer Service Centre,
International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, British Isles.
Privacy policy
Our full privacy policy can be viewed at or can be obtained by requesting a copy from our
Data Protection Ocer.
Policy number
I/We agree to the following receiving an additional valuation statement which will result in a fee being deducted from the policy
cash account.
Name of third party
Policyholder/Trustee/Authorised Signatory Policyholder/Trustee/Authorised Signatory
Date (dd/mm/yyyy)
Trustee/Authorised Signatory Trustee/Authorised Signatory
Date (dd/mm/yyyy)
RL360 Insurance Company Limited. Registered Oce: International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, British Isles. Registered in the Isle of Man number 053002C.
RL360 Insurance Company Limited is authorised by the Isle of Man Financial Services Authority.
PM19a 06/21