POLICY SERVICING FORM – BENEFIT/ PAYOUT
*Policyholder’s Name: _____________________________________ *Policy No.:_______________________
*Email Address: ______________________________ *Mobile No.:__________________ *PAN:____________________
Filling bank details is mandatory as the details are required to process the payouts. To update, provide the details along
*Bank Account Details: with a cancelled cheque and ID proof. (Annexure-1)
Bank Name: ________________________________ Account Type: Savings Current NRE NRO NFC
Account No.: ____________________________________ IFSC Code:___________________________
* I give my consent to Aegon Life Insurance to consider the above-mentioned details as the latest ones & update them in the system across all policies
Please process my payout, for the above mentioned policy, as:
Freelook Surrender Partial Withdrawal Systematic Partial Withdrawal
I am aware of the applicable cancellation charges as per the standard terms and conditions mentioned in the policy
document which I have received.
Please cancel my Policy as: ______________________________________________
(Specify the reasons): ___________________________________________________________________________________
Minimum partial withdrawal amount applicable as per terms and conditions
I want to avail a Partial
Withdrawal Amount. Maximum partial withdrawal available for the policy
Applicable for ULIP. (% of the fund value at the beginning of that policy year as per terms & conditions)
(Tick the relevant box)
Other Amount:
Or
Minimum partial withdrawal amount applicable as per terms and conditions
I want to avail a (Subject to min. of Rs. 2000)
Systematic Partial
Withdrawal Amount. Maximum partial withdrawal available for the policy
Applicable for ULIP. (% of the fund value at the beginning of that policy year as per terms & conditions)
(Tick the relevant box)
Other Amount:
Note:
1. In case the Partial/Systematic Partial Withdrawal amount availed by you (option: Other Amount) is not eligible for processing, then the
maximum eligible Partial/Systematic Partial Withdrawal amount (if any) for the said policy will be paid to you.
2. In case wherein the policy is assigned, if the Partial/Systematic Partial Withdrawal amount is to be paid to the assignor, then
consent of the assignee is mandatory and has to be submitted along with this endorsement form.
3. If the Fund Value or Surrender Value of the policy falls below the minimum value specified in the policy terms and conditions,
policy will be terminated and the Surrender/Fund Value, if any, will be paid. The partial withdrawal under the policy will re duce
the Fund Value.
Non-Resident Indian Questionnaire (To be filled in by the Proposer)
Resident Details
Your Country of Permanent Residence: ________________________________________________________________
Date from which you have become a permanent resident of the country mentioned above: ________________________
Residential Status:__________________________________________________________________________________
Permanent Account Number under Income Tax Act,1961 of India, if any: ____________________________________
Your full address while abroad: ______________________________________________________________________
_______________________________________________________________________________________________
Documentation for NRI:
I have enclosed the list of documents to this effect. (*Mandatory)
Copy of passport – proof of country of residence
TRC – Tax Residency Certificate obtained from jurisdictional tax office of the non-resident policyholder from a country
outside India
Declaration from the policyholder with respect to his/her residential status and country of residence
Address - Indian as well as foreign
Bank name, branch name & address
Please Note:
1. All the above documents/details should be in the name of recipient of payment under life insurance policy. It may be proposer, life
insured, or beneficiary.
2. In case of non-availability of PAN, the TDS rate will be applicable as per tax laws. Hence, providing a PAN copy will be beneficial
for the customer.
3. Processing a payment to a non-resident will take 6-7 working days from the date of receipt of all requisite information. Hence, the policy
holder
needs to be intimated about the timelines for the provision of documents within timelines.
Are you Politically Exposed Person ? Yes No
FATCA details:
Select your current residential status: Indian NRI
Please note: For NRI, TDS deduction, if any, is subject to RBI regulation based on residential status
Loan Request: -To be filled if you want to apply for loan
I want to avail a Minimum loan amount applicable as per product
Loan amount
Maximum loan amount available for the policy (*Surrender value as per terms and conditions)
(Tick the relevant Box)
Value: _________________________
Note:
1. Applicable interest rate will be charged for availing the above mentioned loan amount. If at any point of time,
the outstanding loan amount plus interest exceeds the surrender value, the policy will terminate without
acquiring any value.
2. In case the loan amount availed by you (Option: Value) is not eligible for processing a loan request, then
the maximum eligible loan amount (if any) for the said policy will be paid to you.
3. Loan is not available for the assigned policy.
Declaration & Authorization for Loan request
1. No request shall be deemed to be treated valid and effective unless received by Aegon Life Insurance Company
Limited, (Hereinafter referred to as “the Company”), during the lifetime of the Insured and is finally accepted by the
Company. The receipt of this form by the agent does not constitute receipt/acknowledgment by the Company.
2. I/We hereby request that the terms and conditions of this policy be changed in accordance with the above particulars
with the understanding and agreement that a copy of this request shall be attached to and forms a part of the said
policy.
3. I/We understand that (i) the Company may be unable to process this application if I/We fail to provide any further
information requested by the Company and (ii) I/We have the right to obtain access to and to request correction of
any personal information held by the Company concerning me/us.
4. I/We hereby declare that the information given above are correct and complete and shall inform you of changes if
any. The Company shall not be responsible for delay in credit, amount not credited, amount credit to incorrect
account, due to incomplete or incorrect information herein.
5. I/we understand that the information provided by me/us may be shared with third parties as per legal or regulatory
requirements.
6. I/We hereby undertake to indemnify the company for any loss post assignment that is may sustain for: a. The
wrongful usage of policy document or b. Creation of any third party interest affecting the right of the Company.
Notice of Assignment: I,____________________________________ , the Assignor, hereby give you notice that I have
assigned the above Policy to the Company (Assignee name) and Assigns all monies, benefits and advantages to be
received to the extent of loan against the policy.
Signature of Policyholder: _________________________
Date: _________________________ Place: ________________________
Declaration & Authorization
I,___________________________________________, being the Policy owner herein declare & affirm that the details
provided in the request form are true and correct, while the present request shall be processed only after all the
information/documents, as required by the Insurance Company, stand submitted and received by the Company.
I/We hereby request that the terms and conditions of this policy be changed in accordance with the above particulars with
the understanding and agreement that a copy of this request shall be attached to and forms a part of the said policy.
I consent and agree to indemnify Aegon Life Insurance Company Limited (Insurance Company) in case any wrongful/incorrect
policy benefit is received by me.
Disclaimer
1. In accordance with IRDAI guidelines, if the valid application is received upto 3 pm, the same day closing NAV shall be
applicable and if received after 3 pm, the closing NAV of the next business day shall be applicable.
2. “In the event of any disagreement in interpreting the contents of the format, the format that was printed in Hindi/English version
(as the case may be) prevails as per IRDAI Circular No: IRDAI/ Life/ Life Council/ 2013/ 73 dated 29th April, 2014”
3. The Company will not be responsible for any delay or non-credit due to incorrect banking details
4. The payout settlement is subject to receipt of complete documentation and successful verifications. Additional requirements
may be called for and you may receive a call for verification of facts prior to the settlement
5. Freelook period: I also understand that the refund amount (provided the Free Look has been enforced by me within the
stipulated timeline) will be after deduction of applicable charges
Signature of Policyholder/Nominee/Assignee:
Date: Signature:
Vernacular Declaration
To be submitted if the form is signed in any language other than English or bears the thumb impression of the Policyholder/ Assignor.
I hereby declare and certify that I have explained the content of this form to the Policyholder/Assignor in the language understood by
him/her and that the Policyholder/Assignor has affixed his/her thumb impression/ signature on this form in my presence, after fully
understanding the content thereof.
Name of the Declarant
Signature of the Declarant
Place: Date:_____________________ Contact No
Annexure – 1:
List of KYC Proof:
ID Address
OVDs
Proof Proof
Valid Passport Yes Yes
Valid Driving License Yes Yes
PAN Card Yes No
Aadhar card/ Proof of Possession of Aadhaar card Yes Yes
Voters identity card issued by Election Commission of India Yes Yes
The letter issued by the National Population Register
No Yes
containing details of name, address, etc.
Job card issued by NREGA duly signed by an officer of
Yes Yes
the State Government
Any other document as notified by the Central
Yes Yes
Government in consultation with the Regulator
Please note: All documents submitted need to be self-attested by the Policy owner. Where Aadhaar/proof of possession of
Aadhaar containing Aadhaar Number is voluntarily provided, the customer shall redact or black out first 8 digits of
Aadhaar number.
