FREE LOOK CANCELLATION
REQUEST FORM
Version 4.1
Change in Contact Details (Mandatory valid self attested address proof to be submitted)
*Mobile
*Email
CKYC No.
* Details are mandatory to be filled.
DECLARATION
I hereby submit that I am the holder of an insurance policy with Canara HSBC Life Insurance Company Limited (Company). I would like to voluntarily cancel the
said policy under freelook cancellation provision. I understand that freelook cancellation can be availed within 30 days from the date of receipt of the policy
document. The payout shall be strictly in accordance with the policy terms and applicable IRDAI regulation.
I understand that the premium shall be refunded subject only to deduction of the proportionate risk premium for the period of the cover, stamp duty and medical
expenses (if any).
I understand that my insurance cover along with other benefits as per the terms and conditions of the policy contract will cease to exist with effect from the date of
acceptance of free look cancellation request by the Company.
I hereby declare that the policy details and the bank account details provided by me are true and correct, if provided and I hereby authorize the Company to credit
the proceeds under the above policy to my bank account given, at my sole risk. I confirm and indemnify the Company against all losses/damages incurred by it
due to any obtained by
I/ We authorize the Company to seek/ store or/ and to share my KYC details from/ with (i) Governmental and/ or Regulatory Authority, (ii) Insurance Repositories
(iii) CERSAI/ other authentication agencies (iv) reinsurers/ group companies/ hospital or diagnostic centers/ other insurance companies or third parties for
underwriting assessment, claim investigation/ settlement, KYC authentication (if permitted), off-line verification, policy servicing purpose and such like purposes.
I/we hereby authorize company to send me any information relating to my policy/policies through SMS on the phone number provided by me or through any
other mode.
In case of Aadhaar submitted voluntary as KYC, the record retention and usage will be as per applicable regulations and KYC authentication/off-line verification
shall be for purpose of issuance of insurance policy / servicing.
Date D D M M Y Y Y Y Place
Signature of Policyholder
Policy No :___________________________________________________________________________________
Name of Policyholder:_____________________________________________________________________________
Reason for Free look Cancellation (Please tick from below appropriate reason) :
Product/policy does not meet my expectation Not satisfied with policy terms and conditions
Financial reasons Personal reason
No requirement Other, Please specify _______________________________________________
CUSTOMER ACKNOWLEDGEMENT SLIP (To be filled by Bank branch/HUB official)
Policy Number Request Time H H M M S S
Type of Request _________________________________
Request Date D D M M Y Y Y Y
Documents Original Policy Document Bank account details supporting proof Indemnity bond (if Original policy document not available)
Submitted:
Received by _________________________________
Designation _________________________________ STAMP & TIME
Signature _________________________________
FREE LOOK CANCELLATION
REQUEST FORM
DOCUMENTS REQUIRED
Version 4.1
1) Policy Original Document (Mandatory)*
2) Bank account details for electronic fund transfer (Cancelled Cheque/ Passbook copy/Bank Statement)#
* In case original policy document is not available, please provide Indemnity Bond.
In case customer wants the refund in NRE account then Source of Premium proof (i.e. bank statement showing the debit transaction or Declaration from bank for
#
premium debited from NRE account) would be required.
Note: Bank account details given by the customer need to be self attested. Further, the account number, account holder name, account type must be printed and visible
clearly on the document provided as proof. Company shall not be held responsible in case your bank account is not credited or if the transaction is delayed or not effected
at all for reasons of incomplete/incorrect information provided by you.
INSTRUCTION & DISCLAIMER:
1. In case the form received is incomplete or without the required documents, the Company reserves the right to reject the free look cancellation request. NAV
applicability and processing timelines will be of/from the date when complete requirements/documents received by the Company.
2. The original form will be submitted back to the customer incase request taken through Distributor App.
3. I understand and agree that the submission of this form does not mean that the request will be acceded.
4. In case of Unit Linked Policies, for the requests impacting the funds of the Policy, if application is received before 3:00 pm on a business day, NAV of same
day will be applicable. If received after 3:00 pm, next business day NAV will be applicable.
5. If documents are received by corporate agent or intermediary or agent then it should be attested by them.
PERSONAL DETAILS
Please fill this section incase there is a change in the details already submitted to the Company :
i) Residential Status in current Financial Year (Please Tick) Resident* Non Resident* (As per Income Tax Act, 1961, an individual is resident of India,
if he satisfies any of the following:
i) Is in India in the relevant financial year for 182 days or more; or ii) is in India for 60 days or more in the relevant financial year AND 365 days or more
during 4 years immediately preceding relevant financial year. An Individual who is NOT a resident of India is a Non resident)
ii) *Country of Residence (Mandatory if Non Resident of India)
PAYMENT DETAILS (MANDATORY)
Bank Account Number
Name of the accountholder as appearing in the Bank Account
Bank Name
IFSC Code
Branch Name
Bank Account Type Savings Current NRE NRO
(Payment in NRE / NRO account is not permissible for resident customers. Resident customers are permitted to take the Payment in Saving & current account only.)
#
Non-resident customers or Mariner customers are permitted to take the payment in NRE /NRO account only. Please submit FATCA/CRS Questionnaire available
#
on our website.
Vernacular Declaration (To be filled if Customer has signed in language other than English / Affixed Thumb Impression)
I hereby declare that I have explained the contents of freelook cancellation form/request letter to the Policyholder Mr/Mrs/Ms ______________________________
in___________________ language and that the Policyholder has affixed the thumb impression(s)/signed in language other than English in my presence after fully
understanding the contents thereof.
Name of the Declarant Signature Date D D M M Y Y Y Y Place
Canara HSBC Life Insurance Company Limited
(formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited) IRDAI Regn. No. 136
Head Office Address: 139 P, Sector 44, Gurugram – 122003, Haryana, India
Registered Office Address: 8th Floor, Unit No. 808 - 814, Ambadeep Building, Plot No.14, Kasturba Gandhi Marg, New Delhi - 110001
Corporate Identity No: U66010DL2007PLC248825
Call us at 1800-103-0003/1800-180-0003/1800-891-0003 SMS at 7039004411
E-mail us at customerservice@canarahsbclife.in Visit our website at www.canarahsbclife.com
