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PARTIAL WITHDRAWAL APPLICATION FORM

(For office use only)

Policy No. Date & Time :


Stamp
Branch Name:
Branch Official:
Sign with Seal

I / We _________________________________________ wish to withdraw an amount of Rs.____________ (In words


Rupees______________________________________only) under my above mentioned policy and request you to settle the
partial withdrawal amount against my policy. I/ We understand that if fund value after the partial withdrawal goes below
Rs.10000/- or one annualized premium (whichever is applicable), the policy will be foreclosed and the entire fund amount will
be returned after deducting the applicable charges as per the terms & conditions of the policy.

I also understand and agree that in case of foreclosure of the policy, the policy shall automatically stand cancelled and no
further benefits will accrue under the said policy.

Mode of Payment: Cheque Direct Credit (Tick any one option mandatory)

* The payment will be made by cheque, only in cases where the customer /applicant does not have an account with any of the Scheduled Banks.

Bank Account Details (Mandatory)

Bank A/c No*: _____________________________ Bank Name *: ____________________________

IFSC Code*: _____________________________ Branch Name*: ___________________________

Type of Account*: _____________________________

BANKER’S ATTESTATION

We hereby certify that the account details mentioned above are correct and as per our records.

Signature of Authorized Bank official: __________________________

Full Name with designation & SS No __________________________


(Affix Stamp)

SBI Life Insurance Co. Ltd,


Corporate Office: "Natraj", M.V Road & Western Express Highway Junction, Andheri (East), Mumbai-400069
Central Processing Center: Kapas Bhavan, Plot No.3A, Sector No.10, CBD Belapur, Navi Mumbai-400614

PS-30/Ver1.3/22.3.2011 Page 1 of 2
NOTE:

9 There should not be any corrections in the form. In case of corrections, a fresh form has to be used. The form is liable to be
rejected if there are any corrections/overwriting/erasures.
9 Account Details are mandatory .In case the account number is not mentioned in the form, the payment will not be processed.
9 For NRI/NRE account, letter from the bank stating that premiums are paid through the said account is required, to credit the
partial withdrawal amount to the account.
9 Please provide any one of the following to effect direct credit to bank account:
• Cancelled/ photocopy of cheque leaf along with preprinted name where cheque facility is available.
• Attestation by branch manager of the bank where the bank account is being maintained.
• Photocopy of Passbook front page with photograph and transactions of last six months (Verified by
SBI life Branch official.)
9 Partial Withdrawal facility is not available for pension plans.
9 You are advised to check the fund value before applying for Partial withdrawal to avoid unintended foreclosures.
9 In case of a defective application for withdrawal, the date of receipt of a fresh and valid application for partial withdrawal alone
shall govern in determining the applicable NAV.

Disclaimer: Please note that payment through Direct Credit will be made only when such a facility exists and is allowed by the Bank
concerned. SBI Life will not be responsible or liable for any losses incurred due to incorrect account details provided by the policyholder.

Signature of Witness: Signature of Policyholder/Assignee


(Assignee’s signature in case policy is assigned)

Name of Witness: _______________________ Name:________________________________

Present Address: ________________________ Present Address(Address & Id Proof is Mandatory for policies
issued before 01.08.2006)

_____________________________________________ ____________________________________________

_______________________________________ ______________________________________

Contact no.: ____________________________

Declaration of English Knowing Person in Case the Proposed insured/ Policyholder is illiterate or signing in vernacular.

I hereby declare that I have explained the contents of this form to the Policy Holder in __________________ language and that the
Policy Holder has affixed his/her Signature / Thumb impression on the form in my presence, after fully understanding the contents hereof.

Signature of the person making the declaration: ____________________________

Name & Address: _________________________


____________________________

SBI Life Insurance Co. Ltd,


Corporate Office: "Natraj", M.V Road & Western Express Highway Junction, Andheri (East), Mumbai-400069
Central Processing Center: Kapas Bhavan, Plot No.3A, Sector No.10, CBD Belapur, Navi Mumbai-400614

PS-30/Ver1.3/22.3.2011 Page 2 of 2