Change Request Form

Full Name
Name of the policy owner.

D.O.B

Confirm your personal details are correct.

Address

Email

Your Life Insurance Policy

Insurance Company

Policy Number

I/We request that the insurance company for my policy amend their records to indicate that Life Insurance Direct Australia Pty Ltd is the appointed broker / servicing adviser for the policies listed above. I/We understand that Life Insurance Direct Australia Pty Ltd will receive a trailing commission and where applicable, any adviser service fees based on my / our Policy. I/We have read and agree to the Life Insurance Direct Australia Pty Ltd Refund Service Terms and Conditions and Financial Services Guide and acknowledge that Life Insurance Direct Australia Pty Ltd has not provided me/us with advice regarding the above insurance.

I/We hereby authorise a representative of Life Insurance Direct Australia Pty Ltd to obtain all information necessary regarding the policies as stated above.

Please be advised that a photocopy or facsimile copy of this letter will act as authority, as the original is to remain on my file at Life Insurance Direct Australia.

Date of request

Signature
please use your mouse to sign the request.

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