8/8/2019 Ul Policy Servicing Form

1/2

Policy Servicing Request Form

For any Query Reach Us at 020-30587888 or Mail to life@bajajallianz.co.in

Please remember to collect Acknowledgment letter on submission of this form.kpyaa famakpyaa famakpyaa famakpyaa fama---- jamaa krnao pr rsaIdjamaa krnaopr rsaIdjamaa krnao pr rsaIdjamaa krnaopr rsaId PaaPtPaaPtPaaPtPaaPt krnaa na BalaoMkrnaa na BalaoMkrnaa na BalaoMkrnaa na BalaoM ....

Policy Number. Date :

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 policyholderelectronically into his bank account.

Electronic Payment Fund Transfer will be applicable to Surrenders, Partial Withdrawal, Cancellation of Proposal, Annuity, LoansSurvival Benefits and Maturity.

Bank Name Branch Name

Bank Account No. Account Type Savings Current

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 withElectronic Payout Request.

OPIN / MOBILE / E- Mail Registration Mandate

I would like to avail following value added services provided by Bajaj Allianz Life Insurance Co Ltd:

E-mail _____________________________________________ Mobile No.By signing below, that above mentioned mobile and email address belongs to me and is authentic .Based on the above

mentioned information I hereby wish to apply for Bajaj Allianz Life Insurance company ltds (BALICs) Mobile RegistrationService, as may be made available to me by the BALIC from time to time.

From _________________________ To ___________________________

Name of Rider for Addition / Deletion: ___________________________ Effective From_________________________Note: Any addition of rider is subject to the company underwriting the risk and the company shall not be liable until such time it hasunderwritten the risk and issued intimation to the policy holder and any addition of rider for a traditional policy will be effective from nextpolicy anniversary

I wish to Increase / Decrease Sum Assurance from ___________________ to ________________

Note: Increase in SA is subject to Policy Conditions Increase of SA is subject to the company underwriting the risk and the company shall not be liable until such time it has underwritten

the risk and issued intimation to the policy holder

I wish to allocate my future premiums as indicated :

Note:

The allocation totals to 100% Fund Apportionment doesnt guarantees fund switching

IFSC MICR Code

Name of the Fund Percentage

Addition / Deletion of Rider

Change In Fund Apportionment (Allocation of Future Premiums)*

Chan e In Sum Assurance

Frequency Change

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8/8/2019 Ul Policy Servicing Form

2/2

Policy Servicing Request Form

For any Query Reach Us at 020-30587888 or Mail to life@bajajallianz.co.in

I wish to switch the value of units credited to this policy as indicated below:

From Fund To Fund No Of Units Amount ( Rs)

`

Note: This Fund Switching transaction would be applicable only to the existing funds, and the future premiums shall continue to be apportioned in the same

proportion, as it exists today. The selected fund is applicable for the particular product Switching Charges would be levied as per policy condition

Top-Up Amount :

Note: Minimum amount of Top-Up is Rs.5000/- Max Amount is governed by respective policy conditions

* If the application for fund switch / Allocation is received up to 3 pm on a weekday (Mon Fri), the same days unit value will be applicable. However, if the application isreceived after 3 pm on a weekday, then the next working days unit value will be applicable (when the applicable day is not a valuation day, NAV of the next immediatevaluation day would be considered)

Declaration: I /We hereby request the policy particulars be changed in accordance with the above information furnished by me/us. Further I We agree that company maynot be able to process the request if I / We provided any incorrect/incomplete/inconsistent information.

I/we. The policy owner/trustee/assignee wishto apply for partial withdrawal of theamounts indicated below from the unitscredited to my policy, in the proportion givenbelow.

Declaration: I/We, the policy owner/trustee/assignee in the title of the above policy authorize and request that the above policybe changed in accordance with the above particulars (partially surrendering the units). I/We further agree that any alteration orvariation shall not take effect until the Company is approving the request.

________________________________________

I / we, _____________________________________________________________do hereby acknowledge receipt fromBajaj Allianz Life Insurance Company Limited of the sum of Rupees__________________________________________

I/ we have enclosed the policy document Yes No / we understand that the surrender of the policyor full withdrawal of units result in the termination of the policy. I / we also understand and agree that the policyshall be deemed to have been duly surrendered and the company discharged of all liabilities under it upon paymentof the surrender value. I / we also understand that the contract of insurance shall be deemed to have been dulyterminated on my/our signing this application form for surrender of the policy.

Fund Percentage

Name of the Fund No Of Units Amount (Rs)

Fund Switch (Allocation of Existing Funds)*

Top- Up

Partial Withdrawal

Surrender

Rs.1 Revenue Stamp

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