USD

BANKER’S ORDER FORM

PLEASE CANCEL ANY PREVIOUS DEDUCTIONS IN FAVOUR OF

GUARDIAN LIFE

Please Tick one Day Month Year Please indicate specific dates for Quarterly, Semi-annual and Annual Modes. For Example:
- Quarterly [ 5th Mar / 5th Jun / 5th Sept / 5th Dec ]
- Semi-Annual [ 28th Jun / 28th Dec ]
- Annual [ 1st Mar ]

COMPANY TO QUOTE UNDERMENTIONED INFORMATION WHEN MAKING PAYMENT

Kindly note that Scheduled Lumpsums, as with other Unscheduled Payments, are not reflected in your policy contract. As such, your copy of this Form serves as Guardian Life’s acknowledgement of your instructions to allocate your payments when received accordingly

BO- v.Jan2015
Please complete details overleaf


USD

BANKER’S ORDER FORM


LIST OF POLICIES OWNER’S NAME PREMIUM
AMOUNT
SCHEDULED
LUMPSUM AMOUNT
TOTAL AMOUNT
$ C
$ C
$ C
TOTAL

Kindly note that Scheduled Lumpsums, as with other Unscheduled Payments, are not reflected in your policy contract. As such, your copy of this Form serves as Guardian Life’s acknowledgement of your instructions to allocate your payments when received accordingly

BO- v.Jan2015
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