<p>IT IS HEREBY DECLARED AND AGREED that the following person is deleted under the above mentioned Group Personal Accident Insurance Policy:</p>

<p>Name: -<br />
Address: -<br />
Cel. No.: -<br />
Beneficiary: -</p>

<p>IN VIEW OF THE FOREGOING, return premium and charges<br />
broken down as follows is hereby charged to the account of the Assured.</p>
