CPS0120010081109
Policy Servicing Request Form 1
For Official Use Only
Alteration Done:
Branch Name:
Alteration Denied:
Receipt Date & Time:
Minor/ Major Policy Alterations/
Loan / Surrender Quotes
Employee Code: ______________
Received by:
Signature: __________________
Interaction ID:
Policy Number: ________________________ Email ID *:_____________________________________________________________________________
(First Name)
(Middle Name)
(Last Name)
Policyholder's name:_________________________________________________________________________________________________________
Contact No.*: Off: ______________________/ Res: _____________________________/ Mob: ________________________ (Mobile number is preferable)
* Contact details provided herein will be updated for all future communications. For the customers registered under National Do Not Call Registry, this response will be treated as valid discharge.
CORRECTION IN NAME (Tick One)
Policy Holder
Life Assured
Nominee/ Beneficiary
Appointee
General Rules
The change will be effected in all the policies where the client exists.
For married women with a change in surname, only a declaration for a change in maiden name is required.
For all other requests involving significant name change a Gazette copy is required.
All the supporting documents should be countersigned by the Life Assured / Policy holder.
(First Name)
(Middle Name)
(Last Name)
Name to be changed to: ______________________________________________________________________________________________________
CHANGE IN ADDRESS (Tick One) (Multiple selections allowed in case of common address)
Policy Holder
Life Assured
Nominee/ Beneficiary
Appointee
General Rules
The change will be effected in all the policies where the client exists. Self attested documentary proof of the new address is mandatory .
Call us on our helpline number 186022679999 (local charges apply - DO NOT prefix any country code e.g. +91 or 00) for list of acceptable address proofs.
New
Correspondence address
Permanent Address (Please tick one option)
House / Flat No: __________________Street/Area: _______________________________________________________________________________
Landmark _________________________________________ City / District: _________________State :________________Pin Code:______________
Contact No: __________________/ ____________________ Email Id: _________________________________________________________________
ADDITION / CHANGE OF NOMINEE / BENEFICIARY
CHANGE OF NOMINEE / BENEFICIARY DATE OF BIRTH
General Rules
Incase the nominee / beneficiary is a minor, please fill up the Appointee details below.
(First Name)
(Middle Name)
(Last Name)
Nominee /Beneficiary Name: Mr/Mrs/Ms ________________________________________________________________________________________
House / Flat No: ______________ Street/Area: ___________________________________________________________________________________
City / District: _____________________State :_______________________Pin Code: ____________________Date of Birth:__/__/____ (dd/mm/yyyy)
Contact No: _________________/ ____________________ Email Id: __________________________________________________________________
Nominee/ Beneficiary Relation to the Life Assured: ___________________________Percentage of Nomination: ______%
In case of change in DOB of Nominee or Beneficiary Old Date of Birth: __/__/____ (dd/mm/yyyy) New Date of Birth: __/__/____ (dd/mm/yyyy)
ADDITION / CHANGE OF APPOINTEE
CHANGE OF APPOINTEE DATE OF BIRTH
(First Name)
(Middle Name)
(Last Name)
Appointee Name: Mr/Mrs/Ms _________________________________________________________________________________________________
House / Flat No: ______________ Street/Area: ___________________________________________________________________________________
City / District: __________________________State :______________________Pin Code: _________________ Date of Birth: __/__/____ (dd/mm/yyyy)
Contact No: _________________/ ____________________ Email Id: __________________________________________________________________
Appointee Relation to Nominee/ Beneficiary: ___________________________
Change of Appointee Date of Birth Old Date of Birth: __/__/____ (dd/mm/yyyy) New Date of Birth: __/__/____ (dd/mm/yyyy)
DECLARATION OF NEW APPOINTEE (To be filled incase of change of Appointee)
I hereby accept my appointment as an Appointee to receive the proceeds under the policy on behalf of the Beneficiary/ Nominee who is a minor.
Appointee's Signature: ___________________________ Date: ______________ Place: ____________________
(No thumb impression)
Customer Acknowledgement Copy (Major/ Minor Policy Alterations/ Loan/ Surrender Quotes)
Policy No: _________________ Interaction ID No: ________________________________Policyholder name: ___________________________________
PS Request: _____________________________ Documents accepted:
Customer Relations Officer
Date:
Original Policy Document
Others (specify):_________________________
Branch Stamp
Time:
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1) Request for changes in policy benefits is allowed only after completion of Six months from the date of commencement of policy and at least 15
days prior to the next premium due date.
2) For policy alterations where direct debit method of payment is active, the current mandate will be de-activated post policy alteration. A fresh
Direct Debit Mandate will be required if you wish to opt for/ continue with direct debit facility for your policy. This should be submitted at any
HDFC Standard Life branch at least 30 days prior to the next premium due date.
3) Request for change in policy benefits must be accompanied by the original policy document.
4) Policy servicing charges may be levied as applicable. Please refer to your policy document for details.
REDUCTION IN SUM ASSURED*
Please reduce the Sum Assured of my policy to ` ___________________
INCREASE IN PREMIUM*
Please increase the Premium of my policy from `_______________/-to `. _____________________/REDUCTION IN TERM*
INCREASE IN TERM*
Please reduce the term of my policy to __________ years.
Please increase the term of my policy to __________ years.
DELETION OF RIDER*
I would like to cancel the following riders:
1. ___________________________ 2. ____________________________ 3. ____________________________ 4. _____________________________
CHANGE IN FREQUENCY OF PREMIUM PAYMENT* (Please tick the option)
Annual
Half Yearly
LOAN QUOTE
Quarterly
Monthly
* Auto Debit is mandatory for Monthly mode.
SURRENDER QUOTE
I would like to avail of a policy loan. Kindly provide a Loan Quote.
I would like to know the surrender value of my policy. Kindly provide a surrender quote.
DECLARATION FOR SUVIDHA & CONVENTIONAL PLANS
I / We understand that reduction in premium will reduce the Sum Assured as per the regulatory limits
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I / We agree that reducing the Sum Assured will change the future benefits
Note: 1) Reduction in premium for SUVIDHA plans is permissible only if the Policy Commencement Date is less than or equal to 31/12/2007.
2) Reduction in Premium for SAP Plan is not allowed if the policy is converted after 01/ 08/ 2009.
Declarant Name: _________________________________Signature: _______________________Date: ______________ Place: __________________
DECLARATIONS
Declaration of Life Assured / Lives Assured* / Policy holder
I / We declare that the information I / We have given is factually correct and true. I / We have not withheld any material information
that may influence the assessment or acceptance of this application else the contract based on the above information be void.
Policy Holder(s)/ Assignee* Name: _____________________________________________
Policy holder(s)/ Assignee* Signature: __________________________________________
Date: ________________ Place: ________________________
* For assigned policies, assignee's signature is required. ** In case of joint lives, signatures of both life A and B are required.
Signature
Verified Stamp
Declaration to be made by a third person where:
The life assured has affixed his/her thumb impression / has signed in vernacular / has not filled the application. I hereby declare that I have explained the
contents of this application form to the life to be assured in _____________________language and have truthfully recorded the answers provided to me. I
further declare that the life to be assured has signed/affixed his/her thumb impression in my presence.
Declarant Name: _________________________________Signature: _______________________Date: ______________ Place: __________________
Address: _________________________________________________________________________________________________________________
HDFC Standard Life Insurance Company Limited. Regd. Off: Ramon House, H. T. Parekh Marg, 169, Backbay Reclamation, Churchgate, Mumbai - 400020.
View Premium Calendar, Pay Premium Online, Track fluctuations in the fund value, Print your Annual Premium Statement & lots more!
Visit www.hdfclife.com and register for My Account today!
Call us on our help line 18602679999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00 /
Email us at service@hdfclife.com /
SMS SERVICE to 5676727 to place a call back request.
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