Surrender / Partial Withdrawal Request Form

Policy Number
Life Assureds Name Policy Owners Name Contact no E-mail : ______________________________________________________________ : ______________________________________________________________ : ______________________________________________________________ : _______________________________________________________________

Electronic Payment Mandate

This mandate is a standing instruction to Bajaj Allianz Life Insurance Co Ltd, to transfer the amount to be paid to the policyholder electronically into his bank account. Electronic Payment Fund Transfer will be applicable to Surrenders, Partial Withdrawal requests.

Bank Name Account Number Branch Name Account Type IFSC

The payout mode selected in the Form will be used by company to generate any payouts to the policy holder (Claimant). Payouts would be done in accordance and subject to terms and conditions of the policy. Note: Cancelled copy of Cheque/ Bank Statement/ Bank Passbook Copy not more than 6 months old as on date to be submitted along with Electronic Payout Request.

Savings / Current

I/We___________________________________________________________, the policyholder/trustee/assignee wish to apply for: Partial withdrawal of the amounts indicated below from the units credited to my policy, in the proportion given below: Name Of Fund Number Of Units Amount (Rs)

Total

OR (Select any one) Surrender and I do hereby acknowledge receipt from Bajaj Allianz Life Insurance Company Limited of the amount against surrender of the policy (full withdrawal) which would result in the termination of the policy. I/We also understand and agree that the policy shall be deemed to have been duly surrendered and the company is discharged of all liabilities under it upon payment of the surrender value. I/We also understand that the contract of insurance shall be deemed to have been duly terminated on my/our signing this application form for surrender of the policy.
Declaration: I/We, the policy owner/trustee/assignee in the title of the above policy authorize and request that the above policy be changed in accordance with the above particulars. I/We further agree that any alteration or variation shall not take effect until the Company is approving the request.
Rs.1 Revenue Stamp

_____________________ Signature of Life Assured Date : Place :

_____________________ Signature of Witness Date : Place :

_____ ________________________ Signature of Policy Owner / Assignee Date : Place:

DECLARATION IN CASE i) THIS APPLICATION FORM IS FILLED BY A PERSON OTHER THAN THE POLICY HOLDER OR ASSIGNOR OR/AND ii) POLICY HOLDER OR ASSIGNOR HAS EITHER PUT THUMB IMPRESSION OR SIGNED IN VERNACULAR Declaration by Policyholder:

I hereby declare that the content and purport of this form have been fully explained to me by______________________________________ (Name of person filling the form) in the language understood by me and I declare that whatever has been stated hereinabove has been recorded by _____________________________ ______________________________________ (Name of person filling the form) as per information provided by me.

Thumb Impression/Signature of the Policyholder

Date:

Place:

Declaration by person filling the form: I have explained the contents of this form to the Policyholder in________________________________language and I have correctly recorded the answers provided to me. I, further, declare that the Policyholder has signed/affixed his/her thumb impression in my presence. Declarants Name: ___________________________________________(Name of person filling the form) Declarants Address: ______________________________________________________________ _____________________________________________________________________________________ __________________________ Declarants Signature (Declarant should sign in English Language only and should be a person other than witness) ___________________________ Signature of Witness Date:

Date :

Place:

Place:

Declaration by Office Head(Sales): Office Heads Name: _________________________________ Employee Code: ____________________ Branch Name : _____________________________ Branch Code: ____________________________ Hereby confirm that I have personally discussed with the above PH over surrender/withdrawal request regarding the mentioned policy & benefits of the policy explained in detail. The Customer is willing to: continue with the policy by canceling the Surrender/Withdrawal request, Opt for Partial Withdrawal from the Policy, instead of Surrender , Continue with the Original Surrender/ Withdrawal Request

Signature & Seal of Office Head

Date :

Place:

Declaration by Operations-Incharge: OPS Incharge Name: ______________________________ Employee Code: ____________________ Hereby confirm that I have personally discussed with the above PH over surrender/withdrawal request regarding the mentioned policy & benefits of the policy explained in detail. The Customer is willing to: continue with the policy by canceling the Surrender/Withdrawal request, Opt for Partial Withdrawal from the Policy, instead of Surrender , Continue with the Original Surrender/ Withdrawal Request I have collected the following documents: Original Policy bond (in case of surrender) Notarised Indemnity Bond (in case of surrender) Surrender/Partial Withdrawal Request Form Duly filled & Signed Cancelled Cheque Leaf/Copy of Bank Passbook /Copy of Bank Statement

__________________________________ Signature & Seal of OPS In-charge

Date :

Place:

For any Query reach us at 1800-22-5858/1800-209-5858 or Mail us at customercare@bajajallianz.co.in