Policy Service Request Form - Edelweiss Tokio Life Insurance

POLICY SERVICE REQUEST FORM
nm∞{bgr g{d©g AZwamoY ‡nÃ
ES>obdmBµO Q>mo{H$`mo bmBµ\$ B›Ì`moao›g Hß$nZr {b{_Q>oS> & nßOrH$aU gßª`m 147 & H$manmoaoQ> nhMmZ Zß~a: U66010MH2009PLC197336
E
Policy No. / nm∞{bgr Zß~a:
Date / {XZmßH$: D D
M M
Y Y Y Y
Name of the Policy Holder/ nm∞{bgr YmaH$ H$m Zm_:______________________________________________Tel. No. / \$moZ Zß~a:______________________
Address / nVm: __________________________________________________________________________________________________________
________________________________________________________________________________________Pin Code / {nZ H$moS>:_______________
Change in Name / Zm_ _| n[adV©Z
Life Assured / ~r{_V Ï`{∫$
Policy Holder / nm∞{bgr YmaH$
Change in Name From /
First Name / ‡W_ Zm_
Middle Name / _‹` Zm_
Last Name / Aß{V_ Zm_
n[adV©Z Ho$ ~mX dmbm Zm_:
First Name / ‡W_ Zm_
Middle Name / _‹` Zm_
{ddmh Ho$ H$maU {ddm{hV _{hbm Ho$ Zm_ _| n[adV©Z h˛Am hmo Vmo CZgo AZwamoY h° {H$ dh Bg ‡nÃ Ho$ gmW {ddmh ‡_mUnÃ ‡ÒVwV H$a|
eof A›`, go Anojm h° {H$ do amOnÃ A{YgyMZm H$s gÀ`m{nV ‡{V`m± bJmEß
Last Name / Aß{V_ Zm_
n[adV©Z go nhbo dmbm Zm_:
Change in Name To /
∑
∑
Change in Correspondence Address / nÃmMma Ho$ nVo _| n[adV©Z
New Address
Z`m nVm:
City / District/
State /
Pin Code /
eha/{µObm:
am¡`:
{nZ H$moS>:
(Provide any of the following Address proofs along with this form) / (Bg ‡nÃ Ho$ gmW nVo Ho$ {ZÂZ{b{IV ‡_mUm| _| go H$moB© gm ‡ÒVwV H$a|)
Electricity Bill* /
Telephone Bill* /
Passport /
Bank Statement* /
Ration Card /
Voter’s Card /
nmgnmoQ>©
ameZ H$mS>©
_VXmVm H$mS>©
{~Obr H$m {~b*
\$moZ H$m {~b*
~¢H$ {ddaU>*
Others / A›`:____________________________________ (*{~Obr H$m {~b/\$moZ H$m {~b/~¢H$ {ddaU 3 _hrZo go nwamZm Z hmo)
Driving License /
S¥>mBqdJ bmBgo›g
Change in Contact Details / Email ID / gßnH©$ {ddaU/B©_ob AmB©S>r _| n[adV©Z
New Mobile No. + /
Z`m _mo~mBb Zß~a: +
Landline No. /
Country Code /
Mobile Number /
Xoe H$m H$moS>
_mo~mBb Zß~a
b°›S>bmBZ Zß~a:
Area Code /
Tel. Number /
E[a`m H$moS>
\$moZ Zß~a
New Alternate Contact No./
Z`m d°H$pÎnH$ gßnH©$ Zß~a:
New Email ID /
Area Code /
Contact Number /
E[a`m H$moS>
gßnH©$ Zß~a
Z`m B©_ob AmB©S>r:
Updation of Bank Account Details / ~¢H$ ImVm {ddaUm| H$m AX≤`VZrH$aU
Bank Name/
~¢H$ H$m Zm_
Branch Name/
Branch Address/
emIm H$m Zm_
emIm H$m nVm
Account Holder’s Name/
ImVm YmaH$ H$m Zm_
Account No./
ImVm Zß.
MICR/
E_AmB©grAma
∑ {Q>flnUr: g^r nm∞{bgr ^wJVmZ Cnamo∫$ ImVo H$mo {H$E OmEßJo
∑ `{X AmnHo$ ~¢H$ ImVm {ddaUm| _| H$moB© ~Xbmd hmoVm h° Vmo Hß$nZr H$mo BgH$s OmZH$mar X|.
ÒdrH•$V ImVm ‡_mU: H¢$gÎS> MoH$ / ~¢H$ nmg ~wH$ / ~¢H$ „`m°am
IFSC
AmB©E\$Eggr
Signature of the Policy Holder / nm∞{bgr YmaH$ Ho$ hÒVmja
Addition of Rider / gÂnyaH$ OmoãS>Zm
Choice of Rider (Sum Assured in `) / MwZm J`m gÂnyaH$ (~r{_V YZam{e Èn`moß(`) _|)
Accidental Total and
Payor Waiver
Hospital
Accidental
Term /
Benefit* /
Critical Illness / Death Benefit / Permanent Disability / Cash Benefit /
Total Premium /
Hw$b ‡r{_`_
Jß^ra ~r_mar
X˛K©Q>Zm _•À`w bm^
Ad{Y
AÒnVmb
ZH$X bm^
X˛K©Q>Zm Ho$ H$maU
g_yMr Am°a ÒWm`r AnßJVm
^wJVmZ Ny>Q>
H$m bm^*
Waiver of
Premium /
‡r{_`_
H$s Ny>Q>
N
Y
* Payor Waiver Benefit Rider /
*^wJVmZH$Vm© H$mo ^wJVmZ go Ny>Q> Ho$ bm^ H$m amBS>a:
On Death /
On CI or ATPD /
On Death, CI or ATPD /
_•À`w na
grAmB© `m EQ>rnrS>r na
_•À`w, grAmB© `m EQ>rnrS>r na
(`h V^r bmJy h° O~ ~r{_V Ï`{∫$ Am°a ‡ÒVmdH$ {^fi hm|)
Top-Up Premium / Q>m∞n-An ‡r{_`_
E. AnZo Q>m∞n-An ‡r{_`_ H$m \ß$S> AmdßQ>Z ^a|
Name of the Fund / \ß$S> H$m Zm_
Equity Large Cap Fund / B{π$Q>r bmO© H°$n \ß$S>
Amount (`) / YZam{e (`)
B. Top-Up Amount /
Minimum /
Maximum /
~r. Q>m∞n-An YZam{e
›`yZV_
A{YH$V_
∑ Q>m∞n-An ‡r{_`_ nm∞{bgr H$s eVm] Am°a {Z~ßYZm| Ho$ AYrZ h°
∑ ~r_m {H$E Om gH$Zo H$m ‡_mUnÃ {d{YdV ^aH$a ‡ÒVwV {H$`m OmZm A{Zdm`© h°
Am°a `h ~r_m nÃ {bIZo Ho$ _mZXßS>m| Ho$ AYrZ h°
∑ `100,000/- go A{YH$ Q>m∞n-An YZam{e hmoZo na Am` ‡_mU
(SFIN:ULIF00118/08/11EQLARGECAP147)
Equity Top 250 Fund / B{π$Q>r Q>m∞n 250 \ß$S>>
(SFIN:ULIF0027/07/11EQTOP250147)
Bond Fund / ~m∞›S> \ß$S>
(SFIN:ULIF00317/08/11BONDFUND147)
Money Market Fund / _Zr _mH}$Q> \ß$S>
(SFIN:ULIF00425/08/11MONEYMARKET147)
Price Earning Based Fund / ‡mBg A{Z™J ~oÒS> \ß$S>
(SFIN:ULIF00526/08/11PEBASED147)
Managed Fund / _°Zo¡S> \ß$S>
(SFIN:ULIF00618/08/11MANAGED147)
TOTAL / Hw$b
Change in Premium Payment Method / Billing Frequency / ‡r{_`_ ^wJVmZ Ho$ VarHo$ _|/ {~b H$s Amd•{Œm _| n[adV©Z
Premium payment Method / ‡r{_`_ Ho$ ^wJVmZ H$m VarH$m:
ECS / B©grEg
DIRECT BILL / S>m`aoäQ> {~b
CC Standing Instruction / grgr ÒWm`r AZwXoe
(`{X B©grEg H$m {dH$În {b`m J`m h° Vmo B©grEg _°›S>oQ> Am°a {ZaÒV {H$E JE M°H$ H$s AmdÌ`H$Vm hmoJr) (`{X grgrEgAmB© H$mo MwZm J`m h° Vmo grgrEgAmB© \$m∞_© Am°a H´o${S>Q> H$mS>© H$s \´ß$Q> H$m∞nr AmdÌ`H$ hmoJr)
Billing Frequency Required /
Annual /
Semi Annual /
Quarterly /
Monthly /
{~b H$s Amd•{Œm Ano{jV h°:
dm{f©H$
AY© dm{f©H$
{V_mhr
_m{gH$
Changes in Sum Assured / ~r{_V YZam{e _| n[adV©Z
Increase / ~ãT>mZm
Decrease / KQ>mZm
From ` / Í$nE go :
Required ` / Í$nE Ano{jV:
ZmoQ>: ~r{_V YZam{e _| n[adV©Z nm∞{bgr H$s eVm] Am°a {Z~ßYZm| `m Hß$nZr H$s ~r_mnÃ {bIo OmZo Ho$ _mJ©Xeu {g’mßVm| Ho$ AZwgma ~r_m {H$E OmZo H$s `moΩ`Vm Ho$ ‡_mU Ho$ AYrZ hmoJm.
For Branch Office Use / emIm H$m`m©b` Ho$ {bE
Branch Name / emIm H$m Zm_:__________________________
Staff Name / H$_©Mmar H$m Zm_:___________________________
Staff Sign / H$_©Mmar Ho$ hÒVmja:__________________________
Date / {XZmßH$:______________Time / g_`:______________
a.m./p.m. / nydm©ï/Anamï
Place / ÒWmZ:_____________
Signature of the Policy Holder / nm∞{bgr YmaH$ Ho$ hÒVmja
Date / {XZmßH$: D D
M M
Y Y Y Y
Place / ÒWmZ:________________
nmdVr agrX
{XZmßH$: D D
M M
Y Y Y Y H$mo ___________~Oo nydm©ï/Anamï nm∞{bgr Zß~a: ____________________Ho$ {bE ____________________H$m AZwamoY ‡m· h˛Am h°.
nßOrH•$V H$m`m©b`:
EoS>bdmBµO Q>mo{H$`mo bmBµ\$ B›Ì`moao›g Hß$. {b.,
EoS>bdmBµO hmCg, Am∞µ\$ grEgQ>r amoS>, H$brZm,
_wß~B© - 400098. \$moZ: +91 22 4088 6015,
\°$äg Zß~a: +91 22 4342 8161
emIm H$s _moha/grb
PSRF/Sep 2014/Ver 4.1/Hin
KmofUm: Cn`w©∫$ AZwamoY na hÒVmja H$aVo g_`, _¢, nm∞{bgr YmH$a EVX≤>¤mam `h KmofUm H$aVm/Vr hˇ± {H$ D$na Xr JB© OmZH$mar gÀ` VWm ghr h° Am°a _¢ g^r eVm] Am°a {Z~ßYZm| Ho$ ‡{V gh_V hˇ±.

Download Report