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Surrender Application No:
FULL SURRENDER FORM
ARE YOU TAKING THE RIGHT DECISION FOR YOUR FAMILY?
You have the flexibilfty to withdl'ftw fron1 your pollc-y at any given time Post lock in P~rlod (based on 'f&C, refer policy document for more details)
Ho\~\-etit Js our dutY to lntomi yoll orthe consequi:itkes 6f' not completing the full term,
,& CONSEQUENCES OF SURRENDERING ¥OUR POLICY
1. You will immediately lose valuable life cover to protect your family in case of an emergency.
2. You will tose the opportunity to maximize your returns.
3. You will lose any tax benefits attached to your policy.
4. This decision once processed is irreversible.
L MIOOOW:VOU ARESBIIOIIS AIIOUT YOUR F~MIL~~ FUTURE, CHOOSE FROM OUR CIJ~TOMIZED OPTIONS
I □ □
l
/ I want better returns_
~
[?7J, My investment needs
have changed
I need part of the
money immediately
I can't affont to pay
the next premium □! I
l
II Get a consultation with our
financial advisor for your
Ask for a •Top-up so that your
investments match your
Ask for partial withdrawal*
options so as to not lose out on
Speak with our financial
advisor to buy some time.
! financial planning so that you increased income. your life cover benefitt and
i
!
can earn more returns •.~pplicable oniy for ind1aFirst Savings Plan, ensure continued returns.
I Educ.rtion and Future Plan •uUP's only
tl
Talk to an advisor now! Call our Tollfree no. 1800 209 8700
N ~ C ' to :r::ions'mentioned above. I would like a full refund of my policy.
-~""""""' 22
AT WHAT STAGE ARE YOU
SURRENOERJNG YOUR POLICY?
DID YOU KNOW?
• Buying a new insurance is ~
e,cpenslve as you get olcter
r--1
Vl:Alt 1 VW 2 YEM 3
I
YfN. A
I
YEN. 5 Y(All 6 YEAR 7 YEAR 8 YEAR 9 YEAR 10+
·• Cllanc~s of getting lnsu~ wHI
reduce as you gt0w q(d
OtATli flENHIT FOR THE ENTIRE POLICY TERM
'Illustrative representation.
-·- - -- - - -- --- -
....
F~ OFFICIAL PURPOSE (to ~e fllled by branch agent st,ould be handed over to ...) FORM NO.
I, hereby declare that I have explained the consequences of surrendering this policy to the policyholder.
L - - - - - - - _J
Name & Signature ot Branch Agent
I
L ___ __ _ _ _ _ I
Name and Slgneture of sales representative
hi.First life 1115urwe Ca 1111-111J Ud.,,
12th and 13th Aoor, North [C] Weng. Tower 4, Nesco IT Park. Nesco Center, Tet +91 22 6165 8700 Fax: +9122 6857 0600 Toll Free.: 1800-209-8700
--••·----------------- -------•-- .. ----- -----------M
Westem Express Highway. 6oregaon c·EasO. Mumbai - 400063.
RW Re,d. No. 143 ICft U66010MH2008PlC79.
I understand that pay-outs against Insurance policies are subject to tax deduction at source (TDS) as per 194DA of Income Tax Act,1961,
(effective from 1st September 2019) for Non-Compliant life plans, TDS@ 5% will be deducted at source on the income component where PAN is furnistied.
In the absence of valid PAN, tax will be deducted@ 20% on the Income component. The pollcyholder Is recommended to consult his/ her own tax consultant.
(Applicable to Indian Resident) _
~ understand that the pay-outs against insurance policies are subject to
[email protected]% for Future Plan and Non-Compliant' Life Plans u/s 195 of Income Tax Act
~ ~ased on the information provided In NRI declaration Form (Applicable for NRI)
~ I authorize lndiaFirst lite Insurance to contact me which overrides NONC Regl5tratlon, If any
Instructions:
1. Amount payable on Full Surrender withdrawal is as per the policy terms and conditions. •
2. In case your policy has been assigned, the partial withdrawal/surrender request would be accepted If the consent from the assignee of the policy is received.
3. If an application of full surrender is received in case of Unit linked product up to 3:00 pm 1ST on a weekday (Mon-Fri), the same day's unit value will be applicable.
However, ff received after 3:00 pm 1ST on weekday, the next working day's unit value will be applicable (when the applicable day Is not a valuation day, NAV of next
immediate valuation day will be consldered).Requests received after Friday 3 pm to Sunday will be allocated the NAV of the following Monday/following Working day
4. Release of your withdrawal pay-out will be subject to realization of the last renewal premium payment made.
I, ll.SHO ?If" H At..All\confirm that this decision is in the best interest of my family.
~ 1 - -- -~---
!x
L ----
Signature of Policy_ Holder Name, Signature (Rubber Stamp for Corporate/Firm)
of Assignee for assigned policy
Policy No:
~Policy owner verification mandatory
1. Full Surrender Form 2. Cancelled Cheque Copy/Bank Statement (name and account no Printed) 3. PAN Card Copy 4. NRI Declaration (for NRI)
5. Policy document (In the absence of the original policy document, you are required to submit duly filled indemnity bond (Available on the lndiaFirst
website) on Rs 500/- Stamp paper)
6. Address Proof - All documents needs to Self-Attested of Policyholder is mandatory
I wish to surrender the policy mentioned above in full. I understand that the Surrender/Full Surrender of the units results in termination of the
contract. Please process my request and credit the proceeds to my bank account mentioned below:
Name of Account Holder: ~~.JJiLo.l-1i'1Jt\ltiJ]l~I At:¥!t1 I>EL~~1 [Kl}(£~~J)~OI 0%1i-'3, 8 IFSCCode:
Account Number: f_fiJ~fiJ.-12--J.rhJ~L~S"l~J l3LOlL/ ~l~ 0 · O' ~
t~---J-TT7~E-~J~IRCCode : 1
Bank Name: •~t, ir AJk:-_ lMJAit1Jj~hli<L~ ~T-·1 fil&_,~_f_~ ·1 (<I- i-; . -- ___~
Branch Name
I do hereby state that I have read out and explained the contents of the form to the policyholder in ____ language and he/she have understood ~he same.
I declare that whatever I have staled herein above is true and correct to the best of my knowledge and belief. The policyholder has signed /affixed the thumb impression
atterfully understanding the contents thereof.
Name of the Declarant : ________________ ___ Signature:_X_'_ _ _ _ _ _ _ _ _ _Relation with the Policyholder _ _ _ _ __
Address of the Declarant: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Contact No.: _ _ _ _ _ _ _ _ _ __
I hereby certify that the contents of the form have been clearly explained to me and I have fully understood them. I further certify that the answers recorded in the
form are as per the information provided by me.
,I
~ - Si!n~u~e/~h~m~ i~p~es~io~
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Name & Sign.ature of Branch Official Branch Code/location llequest Date Request Time
lndiaFirst Ute lllsurw:e Company ltd,. Fax: +91 22 6857 0600 Toil Fre-e~ 1800-209-8700
Tel: +91 22 6165 8700
12th and 13th Floor. Nonh [CJ Wing. Tower 4, Nesco IT Park. Ne.sco Center, --• ------------• ·-- •-••-----•--••-----0-------
Western Express llidwaaY. 6orepo,, (East). Mumbai - 400063,
IRDAI Regd.. Na. M-3 ION: U660l0MH2008PLO83679. E-m.aiil: [email protected] ~it.e www..indiafirstife.com
