Surrender Form f4p10

INSURANCE

Policy Cancellation Form ( Surrender Form ) PLEASE FILL THE FORM IN BLOCK LETTERS

Do you know by cancelling your policy you are losing on-

? Your Life cover ? Your Rider benefit ? Opportunity of earning Long term return on your systematic planned investments. To know more you can call us at 1800 200 5577 or SMS "RET"at 5424243 or get in touch with your Agent Advisor in case you need any assistance in understanding your plan or our services. Reason for Surrender

Financial reasons (Immediate Fund requirements,Purchase of Asset,etc.) Unsatisfactory returns Unsatisfactory services Buying a new plan Others,please specify Did you consult any one before taking the decision to surrender: Agent

Friend

Relative

Others (pls specify)________________________________________

We regret your decision and hope you have evaluated all the benefits of continuing with your policy prior to making this application.We thank you for choosing Max Life Insurance as your preferred insurance partner and hope that you will reconsider our products in the near future. Please Note: ? “Your request will be processed, provided the request form has been filled in complete and all mandatory documents have been submitted.” ? “For Unit Linked Products if application is received up to 15:00 hrs IST on a business / working day, the same days NAV will be applicable. However, if

application is received after 15:00 hrs, then the next day declared NAV will be applicable

? In case of address change or details change request, please fill up a separate Policy Service Request Form and submit with valid address proof. ? Max Life Insurance shall not be held responsible for delay or non- receipt of the cheque in case the postal address is incomplete / incorrect in company's

records. ? Max Life Insurance will not be responsible in case of non credit to your or if transaction is delayed or not effected at all for reasons of incomplete/

Incorrect information provided or rejected by your bank. In case requisite information for direct credit is not received or transaction is rejected by bank the payout will be made vide cheque

Mandatory Documents for processing payout Original Policy document submitted by the Policy holder for Surrender request. Self attested valid copy of Photo ID proof, carry original for verification at Branch. Original Cancelled Cheque with pre printed name & number book copy / Bank statement having pre printed name & number in case Cancelled cheque does not have pre printed name and number, carry original for verification at Branch. Latest Details. NRE bank statement reflecting any s paid from NRE .

Do you know New insurance is expensive than insurance purchased at a younger age.Don't surrender! You can also opt for partial surrender to meet your immediate fund requirements and continue with your policy. Low Charges: In Unit linked products, the charges come down significantly after 3rd year resulting in more of your being allocated towards your funds. ULIP thus help you achieve long term goals.

High Growth Potential: Unit linked products may be linked to stock market and your investments grows at a fast pace as compared to many other investments.

Life Cover: Once the policy is surrendered the life cover ceases and you may not get cover when you actually need it the most.

Tax Benefit: You can continue to avail tax benefits under the applicable sections of the Income Tax Act, 1961 subject to any amendment made there to from time to time.

INSURANCE

Policy Cancellation Form ( Surrender Form ) PLEASE FILL THE FORM IN BLOCK LETTERS

Request Form Policy No. Mobile Number

Name of the Policy Holder_____________________________________________________ Alternate Mobile No.

Address 1 ____________________________________________________________________________________________________________________________ Address 2 _________________________________________________________________ Email ID__________________________________________________ City ______________________________________________ State ________________________________________________ Pin

Bank Details for NEFT a)

Pan Card

b)

Bank No...................................................................................

c)

IFSC Code.............................................................................................d)

Bank Name............................................................................................

e)

Bank Address..........................................................................................f )

Holder Name ...........................................................................

Note - Kindly attach a cancelled cheque bearing number and policyholder name or copy of Bank book along with this Form.

Declaration I hereby submit that I am the holder of an insurance policy no. with Max Life Insurance Company Limited. I would like to voluntarily surrender and terminate the a foresaid Policy. I request you to please process the surrender request of my policy and pay the applicable surrender value (if any) after adjusting applicable charges (if any) I. Mr./Miss/ Mrs. ____________________________________________________________s /o , d /o , w/o__________________________________aged___________resident of______________________________________do hereby declare and affirm that the details provided in this Form are correct and accurate. I do hereby agree to receive the surrender value payable under the policy and conditions, after deduction of applicable charges. Further, I confirm that the information provided by me herein is true and correct. I confirm and stand indemnity towards Max Life Insurance for any incorrect or wrongful refund obtained by me. my life cover for___________________ I understand post processing the surrender request for my policy no. _________________________________________along with other benefits as mentioned in policy contract will cease to exist.

______________________________ Signature of Policy Holder

______________

______________

Date:

Place:

Branch Mandatory checklist All mandatory documents as listed above are collected. All copies to be self attested by Policy Owner. All documents are Original seen and verified by the Max Life Insurance Personnel. Received Surrender request on at _______:______ am/pm Retention Efforts made- Yes / No_______________ Reason for Surrender________________________ Pay out to the customer : 1) NEFT process 2) Cheque process

GO STAMP

Acknowledgment Slip We thank you for choosing Max Life Insurance as your preferred insurance partner and hope that you will reconsider our products in the near future. We regret your decision and hope you have evaluated all the benefits of continuing with your policy prior to making this application. Your Request will be processed within 1 0 days of submission at our Branch office. In case you need any clarification or assistance regarding your policy, please call 1800 200 5577 Or SMS 'RET' to 5424243. Max LifeInsurance Co.Ltd. 3rd Floor, Operation Center, 90. A, Udyog Vihar, Sector-18, Gurgaon- 122015,Regd office: Max House 3rd Floor,1 Dr. Jha Marg, Okhla, New Delhi-110020,India Details: Tollfree Customer Helpline:1800.200.55 77 e-mail: [email protected] Visit us at: www.maxlifeinsurance.com

SURRENDER REQUEST CUSTOMER ACKNOWLEDGEMENT SLIP

Policy Number

GO STAMP

Received by __________________________Date & Time of Receipt_________________ Max Life Insurance/SUR/Version 2.2/June’13