Application for Surrender of Policy PDF

IRDA Regn. No. 135. | Corporate Identity Number: U66010MH2007PLC167164.
Tradeview, Oasis Complex, Kamala City, P. B. Marg, Lower Parel (W). Mumbai - 400013.
Toll Free: 1800 209 0502 (Monday to Saturday; 8 am to 8 pm). E-mail: [email protected].
www.idbifederal.com
APPLICATION FOR SURRENDER OF POLICY
(Kindly fill in Block Letters)
GENERAL INSTRUCTIONS
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Amount payable on surrender is as per the policy terms and conditions.
All the required details in the form should be completely filled in.
Once policy is surrendered the policy contract terminates and cannot be reinstated back to inforce.
In case your policy is assigned, the surrender request has to be signed by the assignee and the payment of surrender proceeds will be in the favor of the assignee who is now
the policy owner, unless the assignee provides a NOC in favor of the policy holder in which case the payout will be made to the assignor.
The cut off timings for NAV application in respect of allocation and redemption of units is 3:00 PM. This implies that if the application for surrender is received up to 3:00 PM
on a weekday except holiday, the same day's unit value will be applicable. However, if the application for surrender is received after 3:00 PM on a weekday, then the next
working day's unit value will be applicable (when the applicable day is not a working day valuation day would be considered).
Surrender value will be calculated on completed policy years.
POLICY NUMBER
POLICY OWNER NAME
ADDRESS
City
State
TELEPHONE
NUMBERS
(STD CODE)
PIN
Residence
Office
Mobile
Note: In case of address change or contact details change, please fill up a separate Policy Request Form and submit with valid address proof.
PAN Card
Documents to be submitted (Mandatory requirement): Photo id proof (self attested copy of either of PAN card, Driving License, Aadhar card)
SURRENDER PAYOUT OPTIONS - þ Tick (as applicable)
Fund Transfer (fill-up the details below)
ACCOUNT HOLDER Name
BANK NAME AND BRANCH
BANK ACCOUNT NUMBER
ACCOUNT TYPE
Savings
NRE / NRO*
IFSC CODE
Cancelled cheque leaf along with pre-printed name
If cheque does not contain pre-printed name, then please submit self-attested and Bank attested copy of bank statement/
pass-book showing pre-printed bank account number, account holder name, type of account, address, and IFSC code
(which should be less than 6 months old)
*For NRE/NRO account, letter from Bank/bank statement confirming all the premiums are received from the mentioned account number.
Certification by Customer's Bank (to be provided only in case cancelled cheque leaf/Bank pass book not provided)
We hereby confirm that the above bank details provided are correct and pertains to
Mr./Ms. ___________________________________________________________________________________________
______________________________________________
Name / Emp id/ Signature of the Branch Manager
IFLI/PS/PWSPform/v3/1212
Date
PSR : 3001
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Bank
Seal
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DECLARATION FOR SURRENDER
I/We understand that the surrender of the policy results in the termination of the policy and that I/we are required to return the original policy document to the Company. I/We also
understand and agree that the policy shall be deemed to have been duly surrendered and the company discharged of all liabilities under it upon the payment of surrender value,
notwithstanding the non-production of the original policy document to the company, for any reason. Where the policy is not submitted to the company, the policy owner hereby
agrees to indemnify the Company against all liabilities that the company many incur on account of any claim being made by any other person on the basis of possession of the
policy document or otherwise. I/We also understand that the contract of insurances shall be deemed to have been duly terminated on my /our signing this application form for
surrender of the policy.
In case the policy is absolutely assigned, please specify in whose favour the payment
of surrender proceeds should be made
Assignor
Assignee
I/We have enclosed the policy document
Yes
No
Signature of
Policyholder
Name, signature (and
rubber stamp for
coporate firm) of
Assignee in case of
absolute assignment
Place
Place
Date
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Date
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DECLARATION (By Person filling the form on behalf of the policyholder for forms signed in Vernacular languages or Thumb Impression)
I _____________________________________________________________________________________________________ having known the
policyholder for a period of ________________ do declare that I have explained the nature of the questions contained in this form to the
policyholder. I have also explained that the answers to the questions form the basis for accepting this request for Surrender.
Date
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Y
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Signature of the Person filling the form
on behalf of the policy holder
(For forms signed in vernacular language / Thumb Impression)
WITNESS DETAILS
Witness Name and
Signature
Place
Date
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Witness Contact
Number
IMPORTANT GUIDELINES
1. Cheque submitted along with payout requests should be cancelled/defaced. While doing so, please ensure the account no. / IFS code is clearly visible.
2. Cheque should not be signed
3. Attached snap shot of cancelled cheque for better understanding of customer. Highlighting the following checks.(Pictorial)
• How to put Cancel cheque reflects
• Mentioned Cheque not to be signed at the signature part
• Importance of A/c No. & IFS Code – Highlight this area with comment “Ensure highlighted area is not defected while cancelling the cheque”
Please ensure you do not deface this part while canceling the cheque
Kindly deface the cheque number
IFLI/PS/PWSPform/v3/1212
PSR : 3001
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