Payment instruction form with indemnity if applicable

You may prefer to check Aviva's records before you download this form. If you wish to do this, please refer the matter on in the normal way. If you are unable to do this, you must advise that you have downloaded the Form on the basis of information provided by the customer, without first having checked Aviva's records.

Before issuing this form to any customers you must advise them of the following.

This Form is designed for use with Aviva policies only.

This Form can be considered for:

  • The surrender of a policy with return of the original policy document.
  • The surrender of a policy without the return of the original policy document but with an indemnity in lieu of its production.
  • Single or multiple policyholders (including trustees).

We strongly recommend the parties to seek advice from their own legal and financial advisors to ensure the form is suitable for them before they complete it.

Aviva cannot accept any legal responsibility for any error or loss, however caused, as it is the responsibility of the parties and their advisors to ensure that the Form is suitable for their purposes before they attempt to complete it.

You must advise the customer that this is a standard form and may not always be applicable to their particular circumstances. In particular, Aviva reserves the right to ask for any additional information or documentation it may reasonably require in respect of the identity, address and/or title of the claimant before being in a position to consider making payment. Aviva cannot guarantee that it will make payment on the basis of this Form.

Important notes

The information contained in this item is based on Aviva's interpretation of current legislation and our understanding of HMRC practice at the date shown. It is provided for general information purposes only and should not be relied upon in place of legal or other professional advice. Both the law and HMRC practice will change from time to time and our interpretation may be subject to challenge by the HMRC or other regulatory body. Aviva cannot act as legal advisor for you or your clients. You should always seek appropriate legal or other professional advice.

I have read and understood the above information and wish to proceed on this basis.

WA01188 02/2009
LTS137